NYAPRS Note: As this article notes, parity in behavioral health is not as easy to achieve as making it a legal responsibility for health plans. Managed care companies must interpret medical necessity criteria for services that they aren’t always familiar with. Providers must understand what they are allowed to bill for and how to negotiate with plans for more services. But importantly, consumers must also understand what benefits they are eligible to receive. Educating individuals and providers will be very important as the behavioral health benefit transitions to managed care next year. New medical necessity criteria will include behavioral well-being, and will impact the types of services a consumer can ask for. Knowing what to ask for to help facilitate individual recovery will become the responsibility of the consumer, the care manager, and ultimately the plan. As plans have so far experienced with private products, this will not be a seamless process, but will ultimately benefit recipients and the overall quality of the system.
Mental Health Coverage Problematic
Democrat & Chronicle; Tom Tobin, Staff, 4/7/2014
Health care parity is not a difficult concept to understand. For insurers, it means covering illnesses without doing more for one than is done for another. In theory, at least, it’s about equality and fairness.
But ensuring parity in mental health coverage has been anything but easy in the Rochester area and elsewhere.
Insurers for years fought against a government-set standard for mental health care — a battle they lost on both the state and federal levels years ago. In 2006, Timothy’s Law, named after a 12-year-old Schenectady boy who committed suicide at home after the family’s insurer denied treatment claims, was passed by the state Legislature. It established requirements for insurers based on the idea that mental and physical illnesses should be treated the same.
Strict adherence to the law, resisted at first, remains problematic eight years later.
MVP Health Care, the Rochester region’s second largest insurer, was fined $300,000 by the state last month for failing on several levels to provide parity. Costs may reach into the millions once claims are resubmitted and considered.
The Attorney General’s Office cited MVP for a broad-based failure since 2009 to meet the law’s directives. Coverage was denied time and again for mental-illness treatment that the attorney general found had been provided more routinely for physical illness.
“The plan denied 39 percent of its members’ claims for inpatient psychiatric treatment and 47 percent of its members’ claims for inpatient substance abuse treatment,” Attorney General Eric Schneiderman said in a statement. “That was more than double the plan’s denial rate for inpatient medical claims.”
The state says no other actions are pending against local insurers on the parity issue, though scrutiny will remain.
Achieving parity could get still more problematic, officials said. Unless ratepayers are willing to accept higher premiums or pared services, passage of the Affordable Care Act and the recent adoption of tougher parity rules in Washington could make equitable care costlier and more difficult to enforce.
Excellus BlueCross BlueShield spokesman Jim Redmond said the insurer, the region’s largest, has a procedure by which it assesses claims using “evidence-based criteria.” Medical necessity is one of the standards.
“The criteria are standards that are used to make informed determinations about the medical necessity of requested services or devices,” Redmond said. “In our case, we use a third party’s widely adopted, evidence-based criteria. … We apply these criteria to both medical and behavioral health services.”
However, according to the state attorney general’s action against MVP Health Care, claimants who were denied based on “medical necessity” are now being allowed to resubmit their paperwork — a finding that indicates that, in the state’s view in the MVP case, the “medical necessity” criterion was misused.
MVP spokesperson Jacqueline Marciniak said the insurer would have no comment beyond the specifics of the settlement with the attorney general. In the settlement, MVP agreed to reform its behavioral-health review process so that coverage gaps are filled.
Changes in residential care
Local providers say Excellus has met the parity law adequately since its passage in 2006. But changes to the law made last year during the rule-writing process in Congress have made that success more difficult to achieve, a spokesperson for the New York State Conference of BlueCross BlueShield Plans said.
“Establishing a mental health parity benefit was challenging for the health plans as they had to combine medical with mental health benefits,” spokesperson Deborah Fasser said. “To date, the cost associated with the benefit has been approximately a 3 to 4 percent increase.
“This is an evolving area. Recently, the federal government adjusted their mental health law requirements and as of July 1, 2014, plans must include residential treatment, which was not included previously,” Fasser said.
To oversee the federal mental health parity law, passed in 2008, three separate agencies have a piece of the action: the Department of Labor for health coverage that is part of federally regulated company pensions; the Department of Health and Human Services for other private health plans; and the U.S. Treasury for tax penalties related to non-compliance.
And federal enforcement of parity wasn’t likely until all the bureaucratic rules for the 2008 law were promulgated. That didn’t happen until just recently — six years after the law was passed.
New York state’s parity law supersedes federal law except where federal requirements exceed what the state demands.
“It took longer than usual,” David Shillcutt, a public health analyst at the federal Substance Abuse and Mental Health Services Administration, said of the rule-writing. “It was an extended negotiation with insurers and providers. Our goal is to work cooperatively with them to carry out the law.”
The Affordable Care Act, which reinforces the parity ideal, and its New York iterations have muddied the parity picture even more. As new insurers come into the Rochester market, doctors get confused about coverage networks and patients shop around for insurance they used to get through their employers.
“Doctors are already confused about which (insurance provider) networks they’re in and which they’re not,” said Nancy Adams, executive director of the Monroe County Medical Society. “Those I’ve talked to about this say that one of the problems with parity may be in having the patient understand how their plan covers behavioral health.”