Mental Health Parity Becoming Parity Advocates Presented by

Mental Health Parity: Becoming Parity Advocates Presented by: Disability Rights California Christopher Ogata Christopher. Ogata@disabilityrightsca. org 1

Disability Rights California DRC is a non-profit legal organization that services as California's protection and advocacy system. DRC works to - Stop discrimination against those living with disabilities, - Increase access to education, transportation, housing, and employment, and - Increase access to government benefits, public and private healthcare, and regional center services. www. disabilityrightsca. org Intake Line: (800) 776 - 5746 2

Mental Health Parity Project Helps to advocate for the mental health parity rights of those who have private health insurance. We Provide - Legal Advice - Technical assistance during the appeals process - In some cases, litigation services Christopher Ogata Christopher. Ogata@disabilityrightsca. org 3

Cal. MHSA The California Mental Health Services Authority (Cal. MHSA) is an organization of county governments working to improve mental health outcomes for individuals, families and communities. Prevention and Early Intervention Programs implemented by Cal. MHSA are funded by counties through the voter-approved Mental Health Services Act (Prop 63). Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California’s diverse communities. 4

Objectives - Define mental health parity - Differentiate between California and Federal mental health parity laws - Identify potential mental health parity issues with your insurance plan - Communicate with your insurance company and the state in order to appeal denied claims for mental health or substance use treatment 5

Parity Means Equality Mental health parity laws: - Requires health insurance plans to provide equal coverage for physical and mental health (including substance abuse disorders) - Created in response to unequal coverage and discrimination Image from www. nourishcoaching. com. au 6

Stigma and Discrimination Stigma and discrimination have resulted in disparities between health care for physical and mental health. - Disparity: the condition of being unequal - Stigma: attitudes and beliefs that lead people to reject, avoid, or fear those they perceive as being different - Discrimination: when people act on stigma in ways that deprive other people of rights and opportunities; treating people differently 7

History of Inequality Historically, insurance companies have not covered physical health and mental health/substance abuse disorder benefits equally: - fewer types of services - more restrictions on accessing treatment - higher costs for treatment 8

Moving Towards Parity 1996 Congress passed 1 st federal parity law, the Mental Health Parity Act 1999 California passed the California Mental Health Parity Act (CMHPA) 2008 Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) 2010 Affordable Care Act extended MHPAEA to more health plans 9

Federal vs. California Law Federal Law California Law Does not mandate mental health coverage (However, “mental health and substance use disorder benefits” are one of the 10 “essential health benefits” required by the Affordable Care Act) Mandates coverage Open to all mental health conditions covered by your plan Limited to “severe mental illness” and “serious emotional disturbances” Requires “parity” for annual and lifetime coverage limits, financial requirements, and treatment limitations within each of six categories of benefits Requires coverage for ALL medically necessary treatment 10

Types of Insurance Plans Employer Group Plans Self-Insured Plans Individual Plans Insurance Exchange Plans Fully-Insured Plans Small Self. Insured Plans Small Fully. Insured Plans Large Self. Insured Plans Large Fully. Insured Plans 11

Plans Covered under Original MHPAEA Employer Group Plans Self-Insured Plans Individual Plans Insurance Exchange Plans Fully-Insured Plans Small Self. Insured Plans Small Fully. Insured Plans Large Self. Insured Plans Large Fully. Insured Plans Covered under MHPAEA Plans NOT Covered under MHPAEA 12

Plans Covered under Expanded MHPAEA Employer Group Plans Self-Insured Plans Individual Plans* Insurance Exchange Plans* Fully-Insured Plans Small Self. Insured Plans Small Fully. Insured Plans* Large Self. Insured Plans Large Fully. Insured Plans Covered under expanded MHPAEA Plans NOT Covered under expanded MHPAEA 13

Plans Covered under CMHPA Employer Group Plans Self-Insured Plans Individual Plans Insurance Exchange Plans Fully-Insured Plans Small Self. Insured Plans Small Fully. Insured Plans Large Self. Insured Plans Large Fully. Insured Plans Covered under CMHPA Plans NOT Covered under CMHPA 14

Federal Law California Law Small, Self-Insured Employer Group Plans No No Large, Self-Insured Employer Group Plans Yes No Small, Fully-Insured Employer Group Plans Yes* Yes Large, Fully-Insured Employer Group Plans Yes Individual Plans Yes Insurance Exchange Plans (Covered California Plans) Yes* Yes Type of Plan * MHPAEA does not apply directly, but the MHPAEA’s requirements are incorporated by reference and therefore apply to the plan. 15

FEDERAL PARITY LAWS 16

Federal Parity Law If a health plan offers any mental health or substance use disorder benefits, the plan must • Apply the same Lifetime Coverage Limits and Annual Coverage Limits as physical health benefits. • Ensure that the plan’s Financial Requirements and Treatment Limitations for mental health are “no more restrictive than the predominant financial requirement applied to substantially all physical health benefits. ” 17

Types of Insurance Limits • Maximum amount your insurance will pay in a year Annual Coverage Limits Lifetime • Maximum amount Coverage your insurance will Limits pay over your life • Deductibles • Copayments • Coinsurance • Out-of-pocket Financial expenses Requirements Treatment Limitations • Quantitative Treatment Limits • Non-Quantitative Treatment Limits 18

Types of Treatment Limitations Quantitative Limits: 1. Annual and Lifetime Limits 2. Deductibles 3. Copayments 4. Coinsurance 5. Frequency of visits 6. Number of visits 7. Days of treatment Non-Quantitative Limits: 1. Formulary design 2. Utilization reviews 3. Medical necessity requirements 4. Step therapy 19

The Mental Health Parity Act of 1996 • Maximum amount your insurance will pay in a year Annual Coverage Limits Lifetime • Maximum amount Coverage your insurance will Limits pay over your life If mental health benefits are offered, benefits must be the same as physical health benefits. Does NOT apply to substance use disorder benefits. Applies only to large group health plans (fifty or more employees). 20

MHPAEA of 2008 • Maximum amount your insurance will pay in a year Annual Coverage Limits Lifetime • Maximum amount Coverage your insurance will Limits Financial Requirements Treatment Limitations pay over your life Expands coverage to include substance use disorder treatment • Deductibles • Copayments • Coinsurance • Out-of-pocket expenses • Quantitative Treatment Limits • Non-Quantitiative Treatment Limits 21

Categories of Treatment Six categories of benefits (benefits must be equal in each category for physical and mental health): 1. Inpatient; in-network 2. Inpatient; out-of-network 3. Outpatient; in-network 4. Outpatient; out-of-network 5. Emergency care 6. Prescription drugs 22

Federal Parity Law Applies to: Does not apply to: - All individual plans - Insurance Exchange Plans (i. e. , Covered California) - Large and Small Fully. Insured Employer plans - Large Self-Insured Employer Plans - Medi-Cal Managed Care Plans - Federal Employee Health Plans - Grandfathered small Fully. Insured Employer Plans (plans from before March 23, 2010) - Small Self-Insured Employer Plans - Medicare Plans - Veteran’s Administration health plans 23

Q&A Q. Carol has a self-funded health plan through her employer. Her psychiatrist feels that she needs weekly therapy sessions to treat her depression. After 10 sessions with an in-network provider, Carol got a letter from her insurance that she has reached the cap on therapy sessions for the year. Is this a parity problem? 24

Q&A A. Probably. Limiting the number of visits to a provider is considered a quantitative treatment limitation. The key here is to find out how the health plan’s limitations on outpatient, innetwork care for mental health/substance abuse disorders compare with limitations on outpatient, in-network care for medical disorders. Unless there is a 10 -session yearly limit on sessions with substantially all medical/surgical providers, this cap on therapy sessions is a violation of federal parity laws. 25

CALIFORNIA PARITY LAW 26

CA Mental Health Parity Act of 1999 All health care service plans must provide coverage for the diagnosis and “medically necessary” treatment for nine specified “severe mental illnesses” of a person of any age, and for the “serious emotional disturbances” of a child. Benefits must be covered under the same terms and conditions as applied to physical illnesses. Benefits must be equal for: - Maximum lifetime benefits - Copayments - Deductibles - Other terms and conditions Benefits must Include: - Outpatient services - Inpatient services - Partial hospital services - Prescription drugs (if the plan covers any prescription drugs) - Basic health care services* *Basic health services include Physician Services, Hospital Inpatient Services, Diagnostic Laboratory Services, and Preventative Health Services 27

CA Mental Health Parity Act Severe Mental Illnesses include: - Major depression - Bipolar disorder - Schizophrenia - Schizoaffective disorder - Anorexia - Bulimia - Panic disorder - Obsessive-compulsive disorder - Autism or pervasive developmental disorder 28

CA Mental Health Parity Act Serious Emotional Disturbance - Children with a “serious emotional disturbance” are also protected by the California Mental Health Parity Act. “Serious emotional disturbance” is defined more broadly than “severe mental illness. ” - Includes any disorder in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance abuse disorder or developmental disorder. - The emotional disturbance must also meet the criteria in Welfare & Institutions code § 5600. 3(a)(2). This means that the “serious emotional disturbance” must result in a substantial impairment in two or more categories, and inappropriate behavior according to developmental norms. 29

California Parity Law Applies to: Types of plans: - Health plans that are regulated by the state (individual and small group plans; “fully-insured” large group plans) Groups of people: - Adults who have “severe mental illnesses” - Children who have “severe emotional disturbances” Does not apply to: - “Self-funded” plans (many large employers and unions offer these type of plans) - Medicare - Medi-Cal - Veterans Administration health plans 30

Q&A Q. Anthony was diagnosed with Psychosis NOS last year, and his insurance plan (a stateregulated health plan) would not pay for a partial-hospitalization program. This month, Anthony was diagnosed with Schizoaffective Disorder. Anthony still wants to try the partialhospitalization program, but he’s worried that his plan will not pay for the program. What should he do? 31

Q&A A. Anthony should try asking again for his insurance plan to cover the program. Now that he has been diagnosed with Schizoaffective Disorder, he has additional protections under California’s Mental Health Parity Act. Anthony’s plan is required to provide medically necessary treatment for Schizoaffective Disorder, including partial-hospitalization services. 32

TIPS FOR MAKING THE MOST OF YOUR HEALTH PLAN 33

Know Your Plan Spending 15 -30 minutes reading key parts of your plan’s Evidence of Coverage can save you a lot of time, money and hassle in the future. It’s much easier to figure out your plan’s rules and procedures when you are feeling well. Evidence of Coverage (EOC): - a document (usually a large packet) produced by your health plan that provides details about what your plan covers, how to get services covered, how to appeal a denial, and other important procedures Where to find your EOC: - you should have received a copy when you first enrolled in your plan - if your health plan has a member website, you can usually find your EOC online - you can call your customer service number and ask for a new copy 34

Know Your Plan Questions to answer about your plan: - What mental health/substance abuse disorder services are covered? - Are there any services that I need prior authorization to receive? - Can I get services outside of my plan’s network? What is the procedure? Is there a higher cost (copay or coinsurance)? - What should I do in an emergency or urgent situation to make sure services are covered? - How do I file an appeal? What are the timelines? 35

Evidence of Coverage (EOC) Look for these key words in your EOC’s table of contents, and read the corresponding sections of your EOC: - “Mental health care”; “Behavioral health care” - “Out-of-plan referral”; “Out-of-network services” - “Emergency and urgent care” - “Excluded services”; “Exclusions” - “Prior authorization” - “Grievances and appeals process” 36

If You Get a Denial notice: a letter that informs you that your insurance will not pay for a service you requested (called a pre-service denial) or your insurance will not pay a bill for services you already received (called a post-service denial). What to do: Start by calling your customer service number to find out more about the denial. If you cannot solve the problem by phone, you can appeal the denial. 37

Tips for Calling your Insurance Plan STAY S. H. A. R. P. Share: - your name and health plan ID number - the problem Have on hand: - your insurance card - any denial letters Ask: - name of the representative and reference number for the call - next steps and deadlines Record: - date and time of the call - names and reference numbers - deadlines Plan: - when you will next follow up 38

APPEALS PROCESS 39

Appeals Process Insurance Denial Internal appeal External Review 40

Urgent Health Situations Urgent health situations: A situation where waiting for the standard appeals process could seriously jeopardize your life or your ability to regain maximum function. You have special rights in urgent situations: - You can request an internal appeal and external review at the same time - Much faster timeline (a final decision must be reached as quickly as your medical condition requires—maximum of 4 business days) 41

Appeals Process: Urgent Health Situations Insurance Denial Internal Appeal External Review 42

Internal Appeals - Most health plans have a fairly simple process for submitting an internal appeal. (There is usually a form and/or instructions attached to your denial notice. ) - There may be 1 or 2 levels of the internal appeal. - During the internal appeal process, your insurance company will review your claim again. 43

Internal Appeals Information to include on your written appeal: - name - claim number - insurance ID number - your contact information - your provider’s name - information supporting why the service should be covered 44

External Review An external review or “Independent Medical Review” (IMR) is when doctors who are not part of your health services plan review your case. You can apply for an IMR if your health care services plan denies, changes, or delays a service or treatment because the plan: – determines it is not medically necessary; – will not cover an experimental or investigational treatment for a serious medical condition; – will not pay for emergency or urgent medical services that you have already received. 45

External Review Outcomes Department of Managed Health Care (DMHC) Independent Medical Review (IMR) 2012 Outcomes (Total: 1558) 23%: Denial overturned before IMR 38%: Denial overturned by IMR 39%: Denial upheld by IMR *Statistics are taken from DMHC’s website: http: //www. dmhc. ca. gov 46

External Review Outcomes California Department of Insurance (CDI) Independent Medical Review (IMR) 2012 Outcomes (Total: 453) 37%: Denial overturned by IMR 8%: Denial partially overturned by IMR 53%: Denial upheld by IMR 2%: Request withdrawn *Statistics are taken from CDI’s website: https: //interactive. web. insurance. ca. gov/IMR/f aces/search? _adf. ctrl-state=z 8 j 9 s 39 ns_4 47

Tips for Appeals - Keep asking and appealing—denials frequently get overturned at every stage of the appeal process - Keep your appeals factual and brief - Meet all deadlines - Keep detailed records - Ask for help from your health providers 48

Where to get help: Disability Rights California: Toll Free 800. 776. 5746 / TTY 800. 719. 5798 http: //www. disabilityrightsca. org/ Each Mind Matters: http: //www. eachmindmatters. org/ 49

Disclaimer This area of the law is rapidly developing. These provision are not intended to include all federal and state laws, regulations policy directives or other relevant references. Further legal research is required. The intent here is to provide a general overview of these topics. 50

PEI Statewide Project The PEI Statewide Project is Prop. 63 -funded programs aimed at preventing suicides, reducing stigma and discrimination, and improving student mental health. - Phase I of the PEI Statewide Project, from 2011 to 2015, implemented programs through three initiatives: suicide prevention, stigma and discrimination reduction, and student mental health. - Phase II of the PEI Statewide Project, from 2015 to 2017, continues the three initiative efforts with an added focus around four wellness areas (diverse communities, schools, healthcare, and workplace) to achieve broad activities that reflect a public health/population based approach for advancing community change. 51

PEI Statewide Project The PEI Statewide Project: - Is voter-approved and funded for by counties through the Mental Health Services Act (Prop. 63) - Transforms California’s mental health services approach by uniting California’s diverse communities to embrace mental wellness and delivering the tools individuals need before they reach the crisis point - Provides an up-front investment that will pay off with sustained cost reductions in health, social services, education and criminal justice programs - Is implemented as a coordinated effort by California’s counties for maximum statewide impact and cost effectiveness 52

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