Lets Go Back to the Basics MHPAEA 101
Let’s Go Back to the Basics MHPAEA 101 – HEALTH TRACK Jo-Anne Fameree, Risk & Regulatory Consulting Irvin “Sam” Muszynski, American Psychiatric Association Katie Dzurec, Pennsylvania Insurance Department
Agenda Subtitle 1 • Overview of MHPAEA • • • Timeline Regulatory Provisions Key Terms • QTL and Financial Requirement analysis • NQTL analysis • Resources for Regulators
Overview of MHPAEA Legislative & Regulatory Timeline Oct 3, 2008 MHPAEA passed, amending PHS Act, ERISA, & IRC Feb 2, 2010 Interim Final Rule published July 1, 2010 IFR effective Oct 3, 2009 MHPAEA effective 2008 2009 2013 2010 Mar 23, 2010 Affordable Care Act Nov 13, 2013 Final Rule published Sept 23, 2010 ACA EHB reforms effective Jul 1, 2014 Final Rule effective 2016 2014 Dec 13, 2016: 21 st Century Cures • Support for Patients and Communities Act: Oct. 24, 2018
Overview of MHPAEA Essentials The rules are sequential and interrelated 1. Identify MH/SUD disorder 2. Identify MH/SUD benefit 3. Identify med/surg benefit 4. Classification of MH/SUD and med/surg benefits 5. Financial requirements & QTL 6. NQTL – medical necessity, information disclosure 7. Vendor coordination
Overview of MHPAEA Regulatory Provisions • If a Company provides both med/surg benefits and MH/SUD benefits, then the Company must comply with parity requirements • may not apply any financial requirement or treatment limitation MH/SUD benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all med/surg benefits in the same classification
Overview of MHPAEA Key Terms • Financial Requirements: • • Type – deductibles, copayments, coinsurance, or out-of-pocket maximums Level – the dollar amount or number of visits/sessions • Quantitative (QTL) – determine whether or to what extent benefits are provided based on accumulated amounts, such as annual or lifetime day or visit limits. Expressed numerically Nonquantitative (NQTL) – limit the scope or duration of benefits for treatment under a plan or coverage (e. g. , prior authorization, formulary design, network) • Treatment limitations – limits on benefits based on scope or duration of treatment (e. g. , frequency, number of visits, days of coverage) •
Overview of MHPAEA Key Terms • MH/SUD Disorder – consistent with generally recognized standards of current medical practice • MH/SUD Benefit – services primarily provided in conjunction with treatment for MH/SUD conditions Classifications Subclassifications • • • Inpatient, in-network Inpatient, out-of-network Outpatient, in-network Outpatient, out-of-network Emergency care Prescription drugs Office/all other for outpatient Drug tiering Provider network tiering
QTL and Financial Requirement Analysis For each classification… substantially all and predominant level are based on ratio of expected claims dollar amounts for the covered service to the amounts for ALL covered services YES What is the predominant level (50%)? NO STOP! Cannot be applied to MH/SUD Does the limit apply to substantially all (2/3) of Med/Surg? MH/SUD levels must be equal to or less than the predominant level
Outpatient, In-Network classification • • Copay $244, 728, 384. 78/$717, 781, 326. 50 Coinsurance – $0/$717, 781, 326. 50 Deductible – $206, 965, 525. 50/$717, 781, 326. 50 None of the cost-sharing types meets the substantially all requirement, so no financial requirements can be applied to the MH/SUD outpatient, In-Network classification
Classification: OPTIONAL SUBCLASSIFICATIONOUTPATIENT, IN-NETWORK, OFFICE Service Categories within OUTPATIENT, IN-NETWORK, OFFICE COLUMN 2 COPAY APPLICATION INSTRUCTIONS: Is a copay applied to this service category? If yes, list the copay Dollar INSTRUCTIONS: Amount Applied to the Service Category. If no, List all MEDICAL/SURGICAL service categories within the OUTPATIENT, List Claim Expected Allowed Dollar Amounts put a "N" for every Service Category where IN-NETWORK, OFFICE classification below. (Annual) for each service category listed. there is no copay application. ADULT PREVENTIVE/HEALTH SCREENING EXAMINATION $ 19, 634, 826. 65 N PEDIATRIC IMMUNIZATIONS $ 9, 103, 247. 38 N PEDIATRIC PREVENTIVE/HEALTH SCREENING EXAMINATION $ 5, 694, 170. 52 N PREVENTIVE $ 24, 853, 595. 57 N SCREENING GYNECOLOGICAL EXAM $ 523, 633. 10 N PHYSICAL, SPEECH, AND OCCUPATIONAL THERAPY $ 25, 816, 315. 51 30 PODIATRIC CARE $ 3, 967, 757. 05 30 PROVIDER OFFICE VISIT (FOR ILLNESS OR INJURY) $ 51, 277, 517. 51 20 SPECIALIST OFFICE VISIT, INCLUDING OB-GYN $ 134, 989, 926. 12 40 THERAPEUTIC MANIPULATION $ 14, 817, 696. 12 30 URGENT CARE FACILITY $ 13, 859, 172. 47 30 For every row in COLUMN 2 with an amount AGGREGATE TOTAL OF MEDICAL AND SURGICAL BENEFITS EXPECTED listed, ADD the expected claim dollar amounts CLAIM DOLLAR AMOUNT WITHIN OUTPATIENT, IN-NETWORK, (COLUMN 1) for the service category listed OFFICE CLASSIFICATION $304, 537, 858. 00 within that row. AGGREGATE TOTALS $ 244, 728, 384. 78 DIVIDE the AGGREGATE TOTAL of all rows with COPAY listed (COLUMN 2), indicating copay is applied, by the AGGREGATE TOTAL of COLUMN 1. If the amount listed within this row is not greater than or equal to 2/3, or 66. 67%, the QTL cannot be applied for this plan design. 80. 36% LEVELS OF COPAYS, LOWEST TO HIGHEST $20. 00 $30. 00 $40. 00 COLUMN 1 EXPECTED CLAIM DOLLAR AMOUNT Outpatient, In-Network, Office sub-classification Copay meets substantially all for TYPE, so we go to predominant level to see what the maximum amount can be… START HERE, MOVE DOWNWARD ONE LEVEL UNTIL AGGREGATE TOTAL OF PERCENT (%) OF CLASSIFICATION LEVELS REACH OVER 50. 01%; STOP. APPLIED AT THIS LEVEL THAT IS THE PREDOMINANT LEVEL, TOTAL EXPECTED CLAIM DOLLARS [LEVEL $ AMOUNT DIVIDED BY AND THE HIGHEST LEVEL THAT CAN BE APPLIED AT THIS COPAY LEVEL TOTAL A $] APPLIED TO MH/SUD BENEFITS. $51, 277, 518. 00 20. 95% $58, 460, 941. 00 23. 89% 44. 84% $134, 989, 926. 00 55. 16% 100. 00% 10 TOTAL A: $ 244, 728, 385. 00
NQTL analysis Subtitle 1 NQTLs applied to MH/SUD must be • Comparable to, and • Applied no more stringently Than those applied to med/surg NQTL analysis must be compliant BOTH as written and in operation
NQTL analysis Subtitle 1 • Walk through provisions • Provide examples
MHPAEA Resources for Regulators Subtitle 1
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