Nancy Shea Mental Health Advocacy Services Inc August 16 2017 What This Webinar Will Cover Why this matters What is mental health parity Overview of mental health parity under state and federal laws ID: 660134
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Mental Health Parity: Assuring Equal Access to Treatment for Children and Youth in California
Nancy Shea
Mental Health Advocacy Services, Inc.
August 16, 2017 Slide2
What This Webinar Will Cover
Why
this matters
What is mental health parityOverview of mental health parity under state and federal lawsHow to challenge decisions and policies of insurance companies
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Some Mental Health Facts
20% of youth ages 13 – 18 live with a mental health condition
Suicide is the 3
rd leading cause of death in youth ages 10 – 24.
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Student Related Depression-Related Feelings by Grade Level (2011 – 2013)
7
th
Graders – 25.3%9th Graders – 30.7%
11th Graders – 32.5%
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Co-Occurring Medical-Psychological Conditions
Children with chronic illness and disability are at
3 times greater
risk for psychiatric problemsChildren with chronic illness and no disability are at 2 times greater
risk for psychiatric problems
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Impact
50% of all lifetime cases of mental illness begin by age 14 and 75% by age 24
The average delay between onset of symptoms and intervention is 8 – 10 years
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Why does this matter?
Approximately 50% of students age 14 and older with a mental illness drop out of high school.
70% of youth in state and local juvenile justice systems have a mental illness.
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Why focus on mental h
ealth
p
arity?Historically, insurance companies have provided unequal coverage between physical health care and mental health care.
A form of discrimination
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What is parity?
Examples of what parity is not:
Copays
Inpatient daysPrior authorization
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Parity means equivalent, equal, or comparable treatment
Mental Health parity laws
:
Created in response to unequal coverage and discriminationRequire health insurance plans to provide equivalent, equal, or comparable coverage for physical and mental health (including substance abuse disorders)
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Federal Mental Health Parity Laws
The Mental Health Parity Act of 1996
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
The Patient Protection and Affordable Care Act of 2010
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California Mental Health Parity Law
The California Mental Health Parity Act of 1999
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CA Mental Health Parity Act
Applies to:
Types of plans:
Health plans that are regulated by the state (individual and small group plans; “fully insured” large group plans)
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CA Mental Health Parity Act
Does not apply to:
Types of plans:
“self-funded” plans (many large employers and unions offer these type of plans)MedicareMedi-Cal
Veterans Administration health plans
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CA Mental Health Parity Act
Applies to:
Groups of people
Adults who have a “severe mental illness”Children who have “severe emotional disturbances (SED)”
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CA Mental Health Parity Act
Covered conditions (for adults)
Major depression
Bipolar disorderSchizophrenia
Schizoaffective disorder
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CA Mental Health Parity Act
Covered conditions (for adults)
Anorexia
Bulemia
Obsessive-compulsive disorder
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CA Mental Health Parity Act
Covered conditions (for adults)
Autism or pervasive developmental disorder
Panic disorder
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CA Mental Health Parity Act
Severe emotional disturbances (for children):
Has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
andMeets the criteria in Welfare & Institutions Code section 5600.3(a)(2)
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CA Mental Health Parity Act
WIC Section 5600.3(a)(2)
Substantial impairment in at least 2 of the following areas:
Self-careSchool functioningFamily relationshipsAbility to function in the community
and
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CA Mental Health Parity Act
WIC Section 5600.3(a)(2)
One of the following occurs:
At risk of removal from the home or has been removedImpairment has been present for more than 6 months or is likely to continue for more than one year with treatment
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CA Mental Health Parity Act
WIC Section 5600.3(a)(2)
Displays one of the following: psychosis, risk of suicide or risk of violence
Identified as eligible for special education as emotionally disturbed
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CA Mental Health Parity Act
Coverage must be equal in terms of:
Maximum lifetime benefits
CopaymentsDeductibles
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CA Mental Health Parity Act
Coverage includes:
Outpatient services
Inpatient servicesPartial hospital services
Prescription drugs (caveat)
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CA Mental Health Parity Act
Coverage mandate:
All
“medically necessary” treatment for the listed “severe mental illnesses” or “severe emotional disturbance” must be covered under the same terms applied to physical illnesses.
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CA Mental Health Parity Act
Two important court cases:
Harlick
v Blue Shield of California, 686 F.3d 699 (2012)Rea v Blue Shield of California, 266, Cal. App. 4th 1209 (2014)26Slide27
Federal Laws
Affordable Care Act (ACA)
Created 10 essential health benefits
Expanded existing federal parity laws to more health plans
Expanded appeal rights to more health plans
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Federal Laws
Affordable Care Act (ACA)
Essential Health Benefits include:
Mental health and substance use disorder services
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Federal Laws
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
Apply to following plans:
Employer-based plans (with more than 50 employees)
Qualified Health Plans (plans offered on the Exchange, i.e., Covered California)
All individual plans
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Federal Laws
Apply to (
cont
):Most small group plans
Medi
-Cal Managed Care Plans
Medi
-Cal Benchmark and Benchmark-Equivalent Plans (ACA
Medi
-Cal expansion)
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Federal Laws
Do not apply to following plans:
Grandfathered small group plans (plans from before March 23, 2010)
Medicare Part A and B
Medi
-Cal
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Federal Laws
Do not apply (
cont
):Veterans’ Administration health plans
Tricare
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Federal Laws
Six categories of benefits
Inpatient
; in-networkInpatient; out-of-networkOutpatient; in-network
Outpatient; out-of-network
Emergency care
Prescription drugs
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Federal Laws
Quantitative treatment limits:
Copays
DeductiblesHow often one gets careNumber of visitsDays of treatment
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Federal Laws
Non-quantitative treatment limits:
Formulary design
Utilization reviewStep therapyGeographic proximityTimely access to care
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Appeals Process
Internal review
External review
Consumer complaint
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California Regulatory Agencies
California Department of Managed Health Care (DMHC) regulates health care service plans
DMHC Help
Center1-888-466-2219www.HealthHelp.ca.gov
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California Regulatory Agencies
California Department of Insurance (DOI) regulates health insurance plans.
California Department of Insurance
1-800-927-4357http://www.insurance.ca.gov/01-consumers/101-help/
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Internal Appeals
Insurance plan denies, changes, or delays a service or treatment because
It is not medically necessary
It is for experimental or investigational treatmentIt involves emergency services already received
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Internal Appeals
Must be notified sufficiently in advance to allow time for an appeal
Must be given opportunity to appeal the termination or reduction before it takes effect.
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Internal Appeals
Fairly simple process to file with health plan (usually form and instructions are attached to denial notice)
Insurance company reviews the claim
Must be resolved within 30 days
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External Review
Also known as an “Independent Medical Review” (IMR)
Independent doctor reviews the case
Have 6 months to file an appeal with the DMHC or the DOI
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Urgent Health Situations
Waiting jeopardizes life or the ability to regain maximum function
Internal and external review can be requested at the same time
Final decision must be reached within 4 business days
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Consumer Complaint
General complaint about a health plan, provider, or medical group, including:
Delays in getting an appointment, referral or authorization
Claims, billing and co-payment issuesTerminations or cancellations of coverage
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Consumer Complaint
Access to translation and interpretation services
Finding and in-network doctor, hospital or specialist
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Consumer Complaint
Complaints
about a doctor or
planDoctor or hospital is no longer with your health plan (Continuity of care)
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Timely Access to Care
Non-Urgent mental health appointment (non-physician): 10 business days
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Tips for Appeals and Complaints
Keep asking and appealing – denials frequently get overturned at every stage of the process
Keep your appeals factual and brief
Meet all deadlines
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Tips for Appeals and Complaints
Keep detailed records
Ask for help from your health providers
Get reason for denial in writing
Keep bugging the insurance company
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Lesson Learned
Don’t Take “No”
For An Answer
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Nancy Shea
Mental Health Advocacy Services Inc.
3255 Wilshire Blvd., Suite 902
Los Angeles, CA 90010www.mhas-la.org nshea@mhas-la.org
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Disclaimer
This area of the law is rapidly developing. These provisions 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.
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