Pierce County HealthWatch June 26, 2014

1. Pierce County HealthWatch June 26, 2014 Mike Rust, Chief Operating Officer ABC for Rural Health, Inc. 100 Polk County Plaza, Suite 180 Balsam Lake, WI 54810 (715) 485-8525 miker@co.polk.wi.us

2. ABC for Rural Health, Inc. A Wisconsin-based nonprofit public interest law firm dedicated to linking children and families, particularly those with special health care needs, to health care benefits and services.

3. Patient Protection andAffordable Care Act

4. Affordable Care Act • Open Enrollment – 11/15/2014 – 2/15/2015 • SEP’s • Loss of Minimum Essential Coverage • Changes in life circumstances • Enrollment problems • Exceptional circumstances

5. Loss of Minimum Essential Coverage MEC is cancelled, involuntarily terminated, or ends before January 2015 Loss of job is common Must be involuntary MEC includes Medicaid and BadgerCare New coverage must begin on the 1st day of the month after MEC ended

6. Changes in Life Circumstances • Turning 26 • Moving to where the plans are different • Adding a dependent (marriage, birth, adoption, foster care placement) • In the last 3, new coverage must start the date of that event, regardless of plan enrollment date • Divorce or death must also include loss of MEC

7. Enrollment Problems • Unable to enroll • Error, misrepresentation, or inaction of an official or agent, misconduct, material violation of the contract by a plan • Individuals who were « in line » • Individuals who were denied Medicaid, but not notified until after open enrollment

8. Exceptional Circumstances Losing eligibility for a hardship exemption Surviving domestic violence (until May 30) Loss of HIRSP (Until May 1) Seeking to terminate COBRA (until July 1) Loss of an individual plan outside of open enrollment Service in AmeriCorps, VISTA, NCCC

9. Other Examples Unexpected hospitalization or temporary cognitive disability Natural disaster Technical error between Marketplace and plan Immigration system error Display of incorrect plan data

10. System Appeals Whether you’re eligible to buy a Marketplace plan Whether you can enroll in a Marketplace plan outside the regular open enrollment period Whether you’re eligible for lower costs based on your income The amount of savings you’re eligible for Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP) Whether you are eligible for an exemption from the individual responsibility requirement

11. System Appeals • Send a letter or a Wisconsin appeal form to • Health Insurance Marketplace 465 Industrial Blvd. London, KY 40750-0061 • Wisconsin appeal form location • https://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdf • Appeals may be expedited. You may ask for representation. Should be done in 90 days.

12. Plan Appeals • Your insurer must notify you of denials in writing and explain why: • Within 15 days if you’re seeking prior authorization for a treatment • Within 30 days for medical services already received • Within 72 hours for urgent care cases

13. Internal Appeals Must file internal appeal within 180 days Appeal must be decided within 30 days if you have not received the service and 60 days if you have received the service Then you may seek external appeal You may request an expedited appeal for urgent situations

14. OCI RE: Training Nonnavigator assisters, including certified application counselors, are required to complete 8 hours of health insurance continuing education training annually. Entities must attest to training on an OCI attestation form by October 1 annually This guidance does not apply to navigators.

15. Required Topics Principles of health insurance Wisconsin health insurance laws and regulations Public health program law, regulations and guidance including BadgerCare and Medicare Federal Affordable Care Act law, regulations and guidance Privacy and Security Guidelines - Personally Identifiable Information (PII)

17. ACA Discussion • Provider network issues • Outreach, Education and Enrollment Review • Plans for now and for next open enrollment • Problems • Training and resource needs

18. Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)

19. MHPAEA Basic Requirement A plan may not apply any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation applied to substantially all medical/surgical benefits in the same classification

20. MHPAEA Categories • Financial requirements – e.g., deductibles, copayments, coinsurance, out-of-pocket maximums • Treatment limitations – limit benefits based on frequency of treatment, number of visits, days of coverage, days in a waiting period, and “other similar limits on the scope and duration of treatment”. • Quantitative treatment limitation – expressed numerically, e.g., annual limit of 50 outpatient visits • Nonquantitative treatment limitation – not expressed numerically but otherwise limits the scope or duration of benefits

21. Quantitative A particular type of financial requirement or QTL must apply to substantially all (2/3) of med-surg benefits in a classification before it may be applied to MH/SUD benefits. If requirement applies to 2/3, then permissible level of that limit is set by predominant level that applies to 50%

22. Non-Quantifiable (NQTL’s) • Any non-numerical limits to scope or duration of treatment (processes, strategies, evidentiary standards or other factors) used in applying an NQTL to MH/SUD benefits must be applied comparably and no more stringently than those are applied to medical-surgical benefits

23. Sample NQTL’s Medical management standards Prescription drug formulary designs Standards for provider admission to a network Determination of UCR amounts Requirements to use less costly first Requirements to complete a course of treatment

24. 6 Benefit Classifications Inpatient, in-network Inpatient, out-of-network Outpatient*, in-network Outpatient*, out-of-network Emergency care Prescription drugs *May use sub-classifications of office visits vs all other care

25. Parity Scope & Timeline Applies to both mental health and substance use disorder (MH/SUD) benefits Generally effective for plan years after October 3, 2009. Fully effective 1/1/11. Interim Final Rules issued February 2, 2010 Final Rules issued November 13, 2013 Final rules apply first plan year after 7/1/14

26. General Applicablity • Covers • Fully insured & self-funded large group plans (>50 employees) • Non-federal government plans over 100 (may request exemption) • Individual & small group plans sold on and off the Marketplace • Increased cost exemption

27. Specific Applicability Newly eligible in Medicaid expansion states Incorporated by reference into MA for managed care (state plan) and CHIP (EPSDT) Not applicable to Medicare except for outpatient co-pays (20%) Church plans exempt unless purchase Marketplace plan or state-regulated plan Federal Employee HBP covered TriCare not covered Does not supersede more stringent state parity laws (WI – eg., autism mandate)

28. Final Rule Clarifications

29. Intermediate Care • Parity applies to intermediate levels of care received in residential treatment and intensive outpatient settings • Intermediate care for MH/SUD treatment services must be assigned to the same classification that plans or issuers assign residential treatment for medical-surgical care.

30. Transparency Upon request of a participant or contracting provider, plan administrators must disclose the criteria for medical necessity. Plan documents must be provided within 30 days of a request. The reason for any denial of benefits must be made available automatically and free of charge.

31. Scope of Services Parity requirements for NQTLs are expanded to include restrictions on geographic location, facility type, provider specialty and other criteria that limit the scope or duration of benefits for services (including access to intermediate levels of care, out of state care).

32. Provider Rates The final rule confirms that provider reimbursement rates are a form of NQTL All rate-setting factors must be applied comparably and no more stringently on MH/SUD providers.

33. Items The final regulations clarify that mental health benefits, medical/surgical benefits and substance use disorder benefits each include benefits for items as well as for services.

34. Cumulative Requirements • Definitions: • Cumulative financial requirements – e.g., deductibles (excludes lifetime and annual dollar limits) • Cumulative quantitative treatment limitations – e.g., annual or lifetime day or visit limits • MH/SUD and medical/surgical benefits must accumulate toward the same, combined deductible (or other cumulative requirement/limit) within a classification • In other words, separate but equal deductibles are not allowed (even if a plan uses more than one service provider)

35. ACA & MHPAEA Expands MHPAEA to individual and small group market Requires coverage of MH/SUD services as one of the ten essential health benefits Prohibits annual or lifetime dollar limits on the 10 EHB’s Preventive services (alcohol misuse screening and counseling, depression counseling, and tobacco use screening) are free of cost-sharing Prohibits certain kinds of discrimination

36. ACA Discrimination • § 300gg–5. Non-discrimination in health care • A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

37. Case Example

38. MHPAEA & PPACA • MHPAEA or PPACA solution? • Patients had been seeing QTT’s • Large corporation employers • New plan with major national carrier denied QTT network access • “Both providers are deemed non-participating, ineligible provider and at this time claims will process as non-participating, ineligible provider. • Under ***** policy only licensed practitioners are accepted. Practitioners with a training certificate will not be added. ***** also does not currently recognize the specialty of Advanced Practice Social Worker as a reimbursable provider”

39. SPD General Exclusion • Treatment or services provided by a non-licensed Provider, or that do not require a license to provide: services that consist of supervision by a Provider of a non-licensed person; services performed by a relative of a Member for which, in the absence of any health benefits coverage, no charge would be made; services provided to the Member by a local, state, or federal government agency, or by a public school system or school district, except when the plan’s benefits must be provided by law, services if the Member is not required to pay for them or they are provided to the Member for free

40. Internal Guidance for Behavioral Health • The Behavioral Health provider types that we credential are those licensed by the state. The three digit codes found at the end of the Wisconsin license number are: • 123 - LCSW (Licensed Clinical Social Worker) • 124 - LMFT (Licensed Marriage and Family Therapist) • 125 - LPC (Licensed Professional Counselor) • 057 - PhD, PsyD, and EdD (Licensed Psychologist) • 020 - MD (Psychiatrist) • Only licensed practitioners are accepted. Practitioners with a training certificate' will not be added.

41. Analysis QTT’s are licensed in Wisconsin The SPD does not restrict licensure with reference to training or supervision Restriction here disagrees with the SPD May also be problem with Parity if there is no equivalent Internal Guidance for Medical-Surgical Care

42. MHPAEA Financial Impact

43. Inpatient 10% of large plans out of compliance in 2010 Virtually none in 2011 2009 – 2011 higher copays and deductibles for MH/SUD decreased rapidly For mid-sized employers, between 10% & 16% out of compliance before MHPAEA, and less than 7% after

44. Outpatient 30% of large plans out of compliance in 2010 In 2011, fewer plans out of compliance, but 20% retained higher outpatient, in-network copays for MH/SUD benefits Between 2009 and 2011, dramatic decline in more restrictive copays & coinsurance Before MHPAEA, 50% of mid-size business plans out of compliance. 40% after MHPAEA

45. ER & Rx In 2010 vast majority of large plans complied with parity in Rx 20% higher cost-sharing for MH/SUD ER By 2011, virtually all plans complied with both ER & Rx

46. MHPAEA Quantitative Impact

47. Inpatient In 2010 nearly all large plans compliant on MH 20% more restrictive for SUD By 2011, no unequal dollar limits & 8% unequal day limits (both MH and SUD) 2009 – 2011 dramatic decline in unequal limits Largest drop in unequal day limits (50% - 10%)

48. Outpatient 50% of large plans had unequal visit limits for MH/SUD in 2010 Less than 7% in 2011 30% unequal dollar limits in 2010 Virtually none in 2011 Mid-sized employers, 81% out of compliance in 2008. Down to 13% in 2011.

49. MHPAEA NQTL Impact

50. Non-Quantifiable Treatment Limitations • In 2010, most plans still used more restrictive NQTLs for MH/SUD • Most common: • Precertification requirements • Medical necessity criteria • Routine retrospective reviews for MH/SUD • Reimbursement on lower % of UCR