Let’s Go Back to the Basics - PowerPoint Presentation

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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

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Overview of MHPAEATimelineRegulatory ProvisionsKey TermsQTL and Financial Requirement analysisNQTL analysisResources for Regulators

Agenda

Legislative & Regulatory Timeline

Support for Patients and Communities Act: Oct. 24, 2018

Overview of MHPAEA

Oct 3, 2008

MHPAEA passed, amending PHS Act, ERISA, & IRC

2009

Oct 3, 2009

MHPAEA effective

Feb 2, 2010

Interim Final Rule published

2010

July 1, 2010

IFR effective

Mar 23, 2010

Affordable Care Act

Sept 23, 2010

ACA EHB reforms effective

2013

Nov 13, 2013 Final Rule published

2014

Jul 1, 2014Final Rule effective

2016

Dec 13, 2016: 21st Century Cures

2008

Essentials

Overview of MHPAEA

The rules are sequential and interrelatedIdentify MH/SUD disorderIdentify MH/SUD benefitIdentify med/surg benefitClassification of MH/SUD and med/surg benefitsFinancial requirements & QTLNQTL – medical necessity, information disclosureVendor coordination

Regulatory Provisions

If a Company provides both med/surg benefits and MH/SUD benefits, then the Company must comply with parity requirementsmay 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 maximumsLevel – the dollar amount or number of visits/sessionsTreatment limitations – limits on benefits based on scope or duration of treatment (e.g., frequency, number of visits, days of coverage)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 numericallyNonquantitative (NQTL) – limit the scope or duration of benefits for treatment under a plan or coverage (e.g., prior authorization, formulary design, network)

Overview of MHPAEA

Key Terms

MH/SUD Disorder – consistent with generally recognized standards of current medical practiceMH/SUD Benefit – services primarily provided in conjunction with treatment for MH/SUD conditions

Overview of MHPAEA

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

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

QTL and Financial Requirement Analysis

YES

NO

For each classification…

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

LEVELS OF COPAYS, LOWEST TO HIGHESTTOTAL EXPECTED CLAIM DOLLARS APPLIED AT THIS COPAY LEVELPERCENT (%) OF CLASSIFICATION APPLIED AT THIS LEVEL[LEVEL $ AMOUNT DIVIDED BY TOTAL A $]START HERE, MOVE DOWNWARD ONE LEVEL UNTIL AGGREGATE TOTAL OF LEVELS REACH OVER 50.01%; STOP. THAT IS THE PREDOMINANT LEVEL, AND THE HIGHEST LEVEL THAT CAN BE APPLIED TO MH/SUD BENEFITS.$20.00$51,277,518.0020.95%20.95%$30.00$58,460,941.0023.89%44.84%$40.00$134,989,926.0055.16%100.00%TOTAL A: $ 244,728,385.00

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Classification: OPTIONAL SUBCLASSIFICATION-OUTPATIENT, IN-NETWORK, OFFICECOLUMN 1COLUMN 2Service Categories within OUTPATIENT, IN-NETWORK, OFFICEEXPECTED CLAIM DOLLAR AMOUNTCOPAY APPLICATIONINSTRUCTIONS:List all MEDICAL/SURGICAL service categories within the OUTPATIENT, IN-NETWORK, OFFICE classification below.INSTRUCTIONS:List Claim Expected Allowed Dollar Amounts (Annual) for each service category listed.INSTRUCTIONS: Is a copay applied to this service category? If yes, list the copay Dollar Amount Applied to the Service Category. If no, put a "N" for every Service Category where there is no copay application.ADULT PREVENTIVE/HEALTH SCREENING EXAMINATION $ 19,634,826.65 NPEDIATRIC IMMUNIZATIONS $ 9,103,247.38 NPEDIATRIC PREVENTIVE/HEALTH SCREENING EXAMINATION $ 5,694,170.52 NPREVENTIVE $ 24,853,595.57 NSCREENING GYNECOLOGICAL EXAM $ 523,633.10 NPHYSICAL, SPEECH, AND OCCUPATIONAL THERAPY $ 25,816,315.51 30PODIATRIC CARE $ 3,967,757.05 30PROVIDER OFFICE VISIT (FOR ILLNESS OR INJURY) $ 51,277,517.51 20SPECIALIST OFFICE VISIT, INCLUDING OB-GYN $ 134,989,926.12 40THERAPEUTIC MANIPULATION $ 14,817,696.12 30URGENT CARE FACILITY $ 13,859,172.47 30AGGREGATE TOTAL OF MEDICAL AND SURGICAL BENEFITS EXPECTED CLAIM DOLLAR AMOUNT WITHIN OUTPATIENT, IN-NETWORK, OFFICE CLASSIFICATION$304,537,858.00For every row in COLUMN 2 with an amount listed, ADD the expected claim dollar amounts (COLUMN 1) for the service category listed 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%

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…

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NQTLs applied to MH/SUD must beComparable to, andApplied no more stringentlyThan those applied to med/surgNQTL analysis must be compliant BOTH as written and in operation

NQTL analysis

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Walk through provisionsProvide examples

NQTL analysis

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MHPAEA Resources for Regulators