The Evolution of Mental Healthcare

1. The Evolution of Mental Healthcare Mind-body Integration improves patient outcomes and reduces cost

2. Healthcare Reform • Payment streams for psychiatric and substance use care are distinctive and poorly understood • Scope of the relative sectors – public, commercial, direct state expenditures, self pay are unique • Substantial impact of medical and psychiatric co- morbidity on total cost of all medical care

3. Guiding Principles for Reform: The Triple Aim • Improving the patient experience of care (including quality and satisfaction) • Improving the health of populations • Reducing the per capita cost of health care THE LONG TERM COSTS OF HEALTHCARE – PUBLIC AND PRIVATE ARE UNSUSTAINABLE

4. Treat Mental Illness Like Every Other Disease CHECK UP FROM THE NECK UP

5. Mental Health Parity The Mental Health Parity and Addictions Equity Act (MHPAEA) requires group insurers to ensure that the “financial requirements” and “treatment limitations” that are applicable to mental health and substance abuse use benefits are no more restrictive than the predominant financial requirements and treatment limitations for medical and surgical benefits covered by the plan.

6. Parity for co-payments, visit limits, etc. • Key Concepts • Benefit Classification (Six Coverage Categories) • IP In Network; IP out of Network • OP In Network; IP Out of Network • Emergency • Rx • If MH/SUD benefits are covered within any of these categories they must be covered in all categories that general medical benefits are covered

7. Financial Requirements and Treatment Limits (e.g. visit limits) • To assess whether parity requirements are met one applies the substantially all (66%) and predominant (50%) tests within a coverage category (inpatient in-network) for medical-surgical • The substantially all test is applied first to determine whether a co-payment or co-insurance is the financial requirement that applies to substantially all spending • The predominant test is then applied to determine what level of financial requirement must be in place for behavioral health (e.g. 20% co-insurance)

8. SUBSTANTIALLY ALL A financial requirement or quantitative treatment limitation applies to substantially all medical/surgical benefits in a classification if it applies to at least two-thirds of the benefits in that classification.

9. PREDOMINANT The predominant level of a type of financial requirement or quantitative treatment limitation is the level that applies to more than one-half of medical/surgical benefits in the classification. If no single level applies to more than one-half of medical/surgical benefits subject to a financial requirement or treatment limitation in a classification, plan payments for multiple levels of the same type of financial requirement or treatment limitation can be combined.

10. 5 Parity Law Facts • Parity law only applies to plans that provide mental health benefits. The law does not require plans to provide mental health benefits if they did not already. • Residential treatment and intensive outpatient treatment are included as intermediate levels of care for parity. • Plans must use the same type of authorization and utilization review process for both mental health and medical services • Federal parity law applies to self funded and fully insured large group plans with greater than 50 or 100 employees. A small employer is defined as one that has 100 or fewer employees, but States have the option to use 50 employees rather than 100 for 2014 and 2015. • State parity laws are not preempted by the federal parity law. You may seek proper coverage under state and/or federal parity laws.

11. Parity Victory! • NY Attorney General Eric T. Schneiderman announced Cigna Corp. is required to reprocess and pay hundreds of claims for nutritional counseling for mental health conditions, including eating disorders, to members who were wrongfully denied access to those benefits. • NY state’s parity law mandates that health insurance companies must provide mental health benefits on par with other medical benefits. • Cigna violated this law and limited the number of nutritional counseling sessions to only three visits for patients with mental health conditions while placing no limits on nutritional counseling visits for those with medial or physical diseases.

12. KAISER HEALTH NEWS February 18, 2014 Some Plans Refuse to Cover Medical Costs Related to Suicide Despite Federal Law

13. DOL STATEMENT IN KHN ARTICLE • Under the mental health parity law, health plans generally have to provide mental health and substance use disorder benefits that are comparable to benefits for medical/surgical care. But if a plan denies coverage following a suicide or suicide attempt, it’s probably not a parity issue, according to the DOL.

14. DOL STATEMENT IN KHN ARTICLE • “In the case of a suicide or attempted suicide, it is generally medical/surgical claims that are involved to treat physical injuries” rather than prescription drugs and therapy that would be covered by mental health parity requirements, the DOL spokesperson said.

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