Parity UpdateCalifornia Parity Field Hearing

July 1, 2013

Background•2008 –The Mental Health Parity & Addiction Equity Act (MHPAEA) becomes law; fully effective 1/1/2011

•2010 –The Affordable Care Act (ACA) becomes law

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What is Parity & Why it Matters•State of being equal; especially regarding status or pay

•Historic discrimination in access to care

•Higher out-of-pocket spending•Life expectancy < 30 years•Final regs implementing MHPAEA lagging

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IFR Requires 6 Classes of Benefits•Parity regulations set up 6 classes of benefits:

▫Inpatient in & out-of-network▫Outpatient in & out-of-network▫Emergency care▫Prescription drugs

•Parity Implementation Coalition supports adding:▫Intermediate inpatient in & out-of-network▫Intermediate intensive outpatient in & out-of-

network

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3 Key Parity Issues Must be Resolved•Transparency & disclosure of medical criteria & plan terms▫Without disclosure, no compliance

testing is possible•Non-quantitative treatment limits

▫Need quantitative floor (i.e. 50%) to operationalize parity in medical management

•Scope of service▫Plans are excluding essential levels of

MH/SUD care; including MAT

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Affordable Care Act & Parity• In 2014, ACA expands MHPAEA &

will apply to:▫Benefits provided in new

“exchanges”▫Benefits provided by non-

grandfathered small group & individual plans

▫Benefits provided to new Medicaid population

▫These plans will have to offer a MH/SUD benefit

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Lawsuits Alleging MHPAEA Violations• C.M. vs. Fletcher Allen Health Care

▫ U.S. District Court of VT found plans, rather than patients, have the burden of proof to provide clinically appropriate standards of care to justify treating MH/SUD claims differently than medical

• APA & CT Psychiatric Society filed suit against Anthem in CT

▫ Anthem agreed to use proper CPT codes but other parity issues still pending

• Class action suit filed in NY by NY State Psychiatric Association against UnitedHealth

▫ Key issue: More stringent medical management (NQTL violation)

• More lawsuits to come

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Resources• Parity Implementation Coalition

▫ www.parityispersonal.org

• States & public plans CMS Center for Consumer Insurance Information &

Oversight (CCIIO) 877-267-2323 ext 61565 E-mail: Phig@cms.hhs.gov

• Employer plans DOL Employee Benefits Administration 866-444-3272 www.askebsa.dol.gov

• CA Insurance Commissioner Consumer Assistance Office▫ 1-800-927-HELP (800-482-4833 TDD)▫ www.insurance.ca.gov/0100-consumers/0020-healthrelated/

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