Parity & Equity (MHPAEA) Compliance Checker Disputing the Decisions that Affect Your Bottom-Line

1. Parity & Equity (MHPAEA) Compliance Checker Disputing the Decisions that Affect Your Bottom-Line Patrick Gauthier, Director

2. Parity & Equity • Federal parity law applies only to insurers who choose to cover mental health and substance use disorder services, and then it only applies to certain plan types. • However, federal parity law does not mandate the coverage of mental health and substance use disorder services.

3. Challenges • As patient presents at point of registration, correlating their coverage and benefits with plan types required to comply.

4. Mental Health Parity and Addiction Equity Act of 2008 • Federal mental health parity law addresses the terms under which mental health and substance use disorder services are covered in comparison with medical and surgical services in those plans that choose to offer coverage of these services. • Federal law requires parity in • annual and aggregate lifetime limits, • treatment limitations (days, visits), • financial requirements (co-pay and deductible), and • in- and out-of-network covered benefits.

5. Challenges • Determining: • Annual and lifetime maximum across all medical coverage • Determining whether or not there is a separate behavioral health deductible • Identifying whether or not the plan has differential co-pay in place for primary care vs. behavioral health • Determining how day and visit limitations are applied in medical conditions and discerning whether those limits in cases of behavioral health are applied more stringently • Determining scope and nature of out-of-network benefits where primary care and behavioral healthcare are concerned

6. MHPAEA and Non-Quantifiable Treatment Limitations Non-quantitative treatment limitations include medical management, network inclusion process and standards, step therapy (fail first), and establishment of Usual, Customary and Reasonable rates of reimbursement. Processes, strategies, evidentiary standards, or other factors used in applying the non-quantitative treatment limitations to MH/SUD benefits to MH/SUD in a classification are comparable to and applied no more stringently than what is applied to medical/surgical benefits except to the extent that recognized clinically appropriate standards of care may permit a difference.

7. Challenges • Determining: • Whether or not network admission requirements are more stringent for Behavioral health providers than they are for primary care • Determining whether or not a fail-first policy (at a lower level of care) is in place • Identifying whether or not the plan uses discriminatory methods for establishing rates of reimbursement • Determining whether or not medical necessity guidelines are applied more stringently • Gaining access to standards and justification used when UM staff reach an adverse determination

8. Parity & Equity • Applies to both large fully insured and large self-insured plans. • In addition, it applies to Medicaid managed care plans and to Children’s Health Insurance Program (CHIP) plans. • The ACA builds on federal parity law by expanding its applicability to a number of additional plan types.

9. Challenges • Coverage: • CHIP? • Large fully-insured? • Large self-insured? • Large self-insured though exempt by virtue of being a non-federal public employee plan? • Small group? • Individual policy? • Medicaid traditional fee-for-service? • Medicare?

10. Illinois Parity Law • ASAM • The new law requires medical necessity determinations to be made in accordance with appropriate patient placement criteria established by the American Society of Addiction Medicine (ASAM). • DHS Providers • The Illinois law specifically identifies, by name, community-based providers, licensed or certified through the Illinois Department of Human Services in accordance with the Illinois Alcoholism and other Drug Abuse and Dependency Act.

11. Illinois Parity Law • Residential/Sub-Acute Inpatient - Additionally, in a significant victory for Illinoisans and their providers, the law identifies residential/sub-acute inpatient treatment services under the definition of inpatient treatment, requiring parity in coverage.

12. Affordable Care Act (ACA) and Parity • Specifically, the ACA includes provisions that require (1) compliance with federal parity law by certain plans and (2) the coverage of mental health and substance use disorder services by certain plans.

13. ACA and Parity • The ACA does not change the federal mental health requirements at all. However, it extends applicability of these requirements to three new plan types: • (1) Qualified Health Plans (QHPs, offered through the state Exchanges); • (2) plans offered through the individual market; and • (3) Medicaid benchmark and benchmark equivalent plans that are not managed care plans.

14. ACA and Essential Health Benefits (EHB) • The ACA also requires certain plans to offer coverage of mental health and substance use disorder services, by requiring these plan types to cover the Essential Health Benefits (EHB), which are defined to include mental health and substance use disorder services.

15. EHB • The ACA does not require that specific mental health and substance use disorder services be included as part of the EHB. • The specific services and items that will be a part of the EHB will be determined through the rulemaking process at the state level with federal guidance.

16. EHB • ACA Section 1302(b) requires the essential health benefits to include, at a minimum, services and items in the following 10 categories: (1) Ambulatory patient services. (2) Emergency services. (3) Hospitalization. (4) Maternity and newborn care. (5) Mental health and substance use disorder services, including behavioral health treatment. (6) Prescription drugs. (7) Rehabilitative and habilitative services and devices. (8) Laboratory services. (9) Preventive and wellness services and chronic disease management. (10) Pediatric services, including oral and vision care.

17. Parity in Exchanges • The ACA requires the establishment of Exchanges, health insurance marketplaces where individuals and employers may purchase health insurance. • Plans offered in the Exchanges, the QHPs, must meet a number of requirements, including compliance with federal parity law.

18. Parity in Exchanges • ACA requires all QHPs to comply with federal parity law in the same manner, and to the same extent, that health insurance issuers and group health plans must comply with these requirements. • QHPs will be provided through both the small group and individual markets and may also be offered outside of an Exchange. • In addition, the ACA requires plans offered through the individual market to comply with federal parity law

19. Challenges • ACA doesn’t take full effect in terms of expanded coverage (Health Insurance Exchange and Medicaid expansion) until 2014 • Presidential election in November

20. Exempt from Parity? • Fully insured and self-insured small plans appear to be exempt from compliance with federal parity law. • In addition, federal parity law does not apply to traditional fee-for-service Medicaid or to traditional fee-for-service Medicare

21. Exemptions • Federal parity law contains an exemption for any group health plan (either fully insured or self-insured) of a small employer (employers with between 2 and 50 employees). • In cases where states consider “groups of one” to be small employers, the exemption extends to those groups of one as well. • The ACA did not amend the small employer exemption, and therefore it appears to remain in effect. • However, we can expect many of those covered individuals to procure coverage through the Exchange in the future in which case Parity will apply.

22. Parity in Coverage

23. Challenges • Establishing nature and scope of coverage at admission

24. Appeals Protections • The Mental Health Parity and Addiction Equity Act of 2008 (Parity) guarantees patients and providers access to the medical necessity guidelines used by managed care entities that deny coverage • The Patient Protection and Affordable Care Act of 2010 (Reform) assures patients and providers of fair, professional, and unbiased review of their appeals and grievances via an external or third-party reviewer should the appeal process necessitate escalation. The law affects all new plans beginning on or after September 23, 2010

25. Denials in Context Denials of reimbursementcan occur for administrative and/or medical necessity reasons at the time of claims adjudication/processing Pre-Authorization Concurrent Review Concurrent Review Retrospective Review Denials and Appeals Denials of coverage and/or benefitscan occur at various Utilization Management or UR junctures throughout the episode Service Episode Timeline

26. Denials • Important Distinction:Insurers may refuse access to benefits and reimbursement, but do not deny access to treatment. Only a provider can do that. Insurers simply don’t pay in the case of denied benefits. • Common Types of Denials: • Administrative - patient or provider failed to follow plan rules and broke with requiredprocesses. Can include ineligibility. • Policy: plan has pre-determined exclusions and limitations on reimbursable procedures and providers • Clinical - plan deems recommended treatment is inconsistent with generally-agreed upon standards and guidelines

27. Administrative Denials • The majority of claims denied reimbursement are denied based on administrative reasons • Missing information • Inaccurate information • Time span issues (dates of services, authorizations) • Ineligible patient, service or provider • Coding errors with diagnosis, patient identifier #, NPI (provider identifier), procedure code

28. Policy-Based Denials • Plans’ policies – ideally aligned with State and Federal laws – are found in their documentation, on their web site, and in the Provider Manual. • Policies will describe requirements for utilization review, financial and service limitations, billing procedures, and other aspects of the benefits such as drug formularies. • Policies will also define those services and providers that are specifically excluded from coverage. • Your Best Defense: READ plan policies, manuals and newsletters. Develop summaries of key points for clinical and relevant administrative staff

29. Clinical Denials • When a plan doesn’t concur with admission or treatment based on its understanding, interpretation of, and application of medical necessity standards and guidelines, it’s quite possible that one or more things are going on: • The denial is justified and will be upheld • The provider’s request for coverage is flawed • The reviewer’s judgment or interpretation is flawed • The plan rules are out of step with the law • The guidelines are out of step with reasonable, community, and professional standards for the practice of mental health and substance use disorder treatment

30. First Things First • Establish the following before proceeding: • The request for treatment coverage is/isn’t sound and consistent with plan rules and generally-accepted professional standards for medical necessity • The plan reviewer’s clinical and/or procedural judgment is/isn’t inconsistent with the law and/or generally-accepted professional standards for medical necessity • Plan’s rules and policies are/are not consistent with Federal and State laws, rules and regulations • Plan’s medical necessity and level of care guidelines are/are not consistent with generally-accepted standards

31. Part 2: The Appeals Process Remember: • Appeals can and should be made by patients and providers but not by both at the same time. • Your patients will need your guidance and tools when making appeals. You may want to dedicate resources and develop patient tools such as template letters. Important Stakeholders Include: • The plan’s Customer Service department, Utilization Reviewers’ supervisors, the Medical Director and Director of Appeals and Grievances • Insurance Agents and Brokers representing the patient’s employer • The Department of Insurance (Commissioner) in your state

32. Appealing Decisions • Three Levels • Level One (internal) • Level Two (internal, escalated to medical director) • Level Three (external review) Expediting Appeals: Appeals can move more quickly (1) if the patient is in the hospital or (2) if the service has not yet been provided. Emergent/Urgent Appeals (concerning the life and wellbeing of the patient will be “fast-tracked” by the plan in order to respond within 1-3 days depending upon circumstances. If the need is emergent or urgent, use this mechanism and be sure to let the plan know.

33. Appealing Decisions • Plans must provide written appeals instructions. • Third-level appeals may be heard by a panel consisting of other providers and professionals requiring you to appear before them to make your case. • Third-level appeals may be reviewed by a qualified medical professional assigned by the state. • Some plans in some states may require arbitration to settle disputed appeals

34. External Review • Under the new Federal law, plans will have to: • Allow claimants the opportunity to request an external review within four months of adverse determination • Complete a preliminary review within 5 days establishing: • That claimant is/was covered by the plan • That claimant exhausted internal processes • That claimant provided all necessary information Then, within 1 day, the plan must indicate to the claimant whether the appeal meets criteria for external review. If information is missing, the plan must enable the claimant by providing instructions and time to re-submit the appeal correctly. Once the claim is deemed appropriate for external review, the plan will forward it within 5 days to an Independent Review Organization (IRO) for their review. The IRO has 45 days.

35. External Review • External Review (3rd level appeals) almost always require that the dispute concern the medical necessity of services • Also, External Review cases almost always require that services have been provided

36. Fast Facts • Experts agree that claims denials represent 15%-20% of your revenue • More than 50% of appeals are won by patients and providers • Residential, Partial, IOP and services that exceed 15-20 visits are among the most often denied for coverage

37. Appeals Processes • Coordinate with patient. Only one of you should appeal. • Note the kind of insurance coverage the patient is covered by (fully-insured, self-insured plan, individual policy, etc.) as some of these are exempt from parity, for instance. • Requestand review plan policies and other documentation (be prepared!) • Requestand review the medical necessity criteria used by the plan to arrive at their decision. • Requestand review the specific justification for the denial. Does it align with the plan’s criteria?

38. Appeals Processes • Document the name and telephone number of the individual you spoke with and note date and time. Ask if they are recording the call and make a note of the answer. • Keep all correspondence including email together. • Verify that pre-authorization is clearly required for your services. • Verify your services are not clearly excluded from coverage.

39. Appeals Processes • Requestand review the timetable for submitting an appeal and that of the entire process. Some plans require that appeals be made within 180 days of the adverse determination. • Plans are required to respond within a certain timeframe depending upon circumstances. If you don’t get a timely response, follow-up!

40. Appeals Processes • Precisely follow the process, instructions and use any forms required by the plan. • Identify the appropriate person for your appeal. • Prepare to write a letter with specific consideration for the clinical needs of the patient as well as the clinical justification for the service you want covered. • Include references to standardized screening and assessment results as well as the individualized treatment plan.

41. Appeals Processes • Include any appropriate references to the parity law or health care reform. Make sure you understand what you’re positing. • Verify that comparable medical services require comparable utilization review and are subject to comparable guidelines. It’s the health plan’s responsibility to demonstrate to you that MH/SUD services are managed “no more restrictively than” medical and surgical services. • Verify that financial and frequency of treatment limitations are not more stringent for MH/SUD conditions and services than they are for medical/surgical.

42. Appeals Processes • Request and review the plan’s policies concerning “scope of service” • the list of covered conditions • the list of covered services • verify that you are a covered provider • Your appeal will document that you (provider), the service you’re requesting (level of care) and the condition (patient’s diagnosis and severity of illness among other factors) are all covered per the law and the plan’s Evidence of Coverage or Summary Plan Description.

43. Request for Medical Necessity Criteria • Your name, credentials, business (facility) name, National Provider Identifier (NPI), physical address, phone number, email address • The appeal liaison’s name, address, phone number, etc. • The patient’s name, subscriber number (insurance policy #) • Date of request for coverage • Name of UR staff who denied coverage • Level of Care Requested/Denied

44. Request for Medical Necessity Criteria • Statement that a licensed clinician has determined—using standardized screening, assessment and diagnostic tools and evidence-based treatment protocols—that a particular level of care and course of treatment was medically necessary. • Statement of need (what would happen if patient did not receive the treatment services requested). • Formal request for the medical necessity criteria relied upon by plan’s utilization review staff in order to reach a decision resulting in denial of coverage for requested treatment services. • Request that plan explain clearly how the managed care processes (including pre-authorization), strategies (including concurrent review), and evidentiary standards used in making the adverse determination are/were applied no more stringently for the MH/SUD services you requested than they are for medical and surgical coverage requests.

45. Appeal Letter • Tailor your wording to use terminology used by plan in the Explanation of Benefits, Provider Manual, and Medical Necessity Criteria • Include references to scientific and professional evidence supporting the level of care requested. Sources include ASAM and CSAT. • Include clinical/medical details supporting your patient’s condition, diagnosis and need for the service you are requesting • Refer to your analysis of the plan’s policies, the law and the plan’s evidentiary standards in contrast to your request. Point to what you believe to be the fundamental problem with the denial and support your conclusion using the plan’s terms.

46. Persistence • Remember there are three levels of appeal and external review is increasingly available • Appeal a second, third and fourth time • Your state may have an Ombudsman • Every state has an Insurance Commissioner

47. Thank You! Questions? Patrick Gauthier Director 888-898-3280 ext. 802 pgauthier@ahpnet.com