Today, NY State sent a letter to insurance companies, telling them they better comply with parity laws, and that they'll be checking up to make sure the insurers are keeping in line. Specifically, the letter was written to "remind" insurers that
MHPAEA (Mental Health Parity and Addiction Equity Act) prohibits issuers whose
policies or contracts provide medical and surgical benefits and MH/SUD benefits from applying
financial requirements, quantitative treatment limitations (“QTLs”), and NQTLs to MH/SUD
benefits that are more restrictive than the predominant financial requirements or treatment
limitations that are applied to substantially all medical and surgical benefits covered by the plan...
...state regulators [will] further review the processes, strategies, evidentiary standards, or other factors used inapplying the NQTL to both MH/SUD and medical and surgical benefits to determine parity compliance:
• preauthorization and pre-service notice requirements;
• fail-first protocols;
• probability of improvement requirements;
• written treatment plan requirement; and
• other requirements, such as patient non-compliance rules, residential treatment limits,
geographical limitations, and licensure requirements.
Accordingly, issuers are advised that the Department of Financial Services will be reviewing
issuers’ NQTLs and QTLs to ensure that issuers fully comply with MHPAEA and will take
necessary action in the event of any non-compliance.
Some additional NQTLs are:
"...treatment limitations based on geography, facility type, provider specialty, and the criteria limiting the scope or duration of benefits or services."
This is a good idea, enforcing rules for insurance companies. But I worry about certain bad ideas. In fact, I have a sneaking suspicion that insurance companies pay lawyers or others so inclined large sums of money to sit around all day and come up with new bad ideas by finding ways to comply with parity laws, but still hinder or delay reimbursement.
I've written previously about one of these bad ideas, namely, an insurance company's demand that I provide proof that my patient requires out of network services. I almost fell for this and started researching articles on continuity of treatment, etc., until Dinah from Shrink Rap pointed out that the insurance company doesn't need to cover out of network services, but if they do cover out of network, the patient doesn't need to justify not using in-network care.
Other egregious examples are stalling and finally informing the patient that the claims were never submitted, or that they were lost, and then sometimes even more egregiously, when the claims are resubmitted, the insurance company comes back and says it's too late to submit.
Or prior authorization. I tried to get Brintellix, now Trintellix (because Brintellix sounds too much like some other drug) approved, got rejected, appealed by filling out a long form that met every criterion for approval, got rejected again, and finally decided it's a crappy drug anyway, and not worth the effort.
A recent gem involved asking the patient's spouse, who is the primary insured, to call the insurance company to verify or "prove" that the patient has no other insurance (Doesn't, never did).
And I'm quite convinced that these stalling tactics are effective overall, because some percentage of them will not be pursued by patients. That percentage is a gold mine for insurance companies. And mental health patients are perhaps more susceptible than most to this hindrance, since things like depression, psychosis, and anxiety can get in the way of accomplishing tiresome, long, and frustrating tasks like talking to insurance companies.
Anyone else have insurance horror stories?
Showing posts with label parity act. Show all posts
Showing posts with label parity act. Show all posts
Wednesday, July 27, 2016
Thursday, June 23, 2016
Virtually Certified
A while back, I wrote about HealthTap, a platform that allows people to ask doctors questions in almost real time. The company was also developing a system for virtual care, and I recently received an email suggesting I take an online course, worth 2 CME credits, to be certified in said virtual care.
I was curious about the progress in this field, so I did take the course, and am now officially certified. I also accidentally clicked an "okay" button, thinking it would allow me to print out my certificates. But it was the wrong button. The button I wanted said, "certificate only", but I didn't see it in time. The "okay" button indicated that I was allowing myself to be part of the HealthTap network of physicians. I didn't really want that, but I suppose it doesn't matter since I'm not going to do anything with it. So watch out for this if you decide to try it.
What I was mainly interested in, in the course, were the legal and regulatory issues related to virtual care. And I did learn a couple things. For instance, you do need to be licensed in your patient's state in order to provide virtual care. I don't know if that means the state where the patient resides, or just the state the patient is in when seeing you. I would guess the latter, since I can treat patients, in person, who live in neighboring New Jersey or Connecticut for example, where I'm not licensed, as long as they see me in my New York office.
Incidentally, you don't need to be licensed in any particular state to virtually treat patients outside the US.
The course referenced the Interstate Medical Licensure Compact, which, "Creates a new pathway to expedite the licensing of physicians seeking to practice medicine in multiple states. States participating in the Compact agree to share information with each other and work together in new ways to significantly streamline the licensing process."
A number of states have already enacted legislature that will allow this expedited pathway to proceed, and other states have introduced such legislation. Still others, such as New York, have done neither. One interesting point I noted is that in order to use this expedited system, you need to be primarily licensed in a state that has already enacted the legislature. So if I want to virtually care for patients in Montana, which has enacted this legislature, I can't, because I'm licensed in New York, which hasn't.
That point is irrelevant, though, since there is currently no administrative process for applying for this pathway, although they state that there, "...will be soon."
The video mentioned that there are CPT codes for virtual care, ranging from 99441 for a 5-10 minute telephone Eval/Management consultation, to a 99444 for an online E/M, to a 99446 inter-professional 5-10 minute consult, to a 99490 > 20 minutes of chronic care management. But most virtual care billing is done using the same CPT codes that would be used for a regular office visit, with a GT modifier, e.g. 99213 GT.
Most importantly, 25 states with parity laws, plus Washington DC, have enacted "...legislation requiring private insurers to pay for Virtual Care at the same level as equivalent in-person services, provided the care is deemed medically necessary."
According to this document, in New York, "The law requires telehealth parity under private insurance, Medicaid, and state employee health plans. The law does restrict the patient setting as a condition of payment."
This image depicts which states make it easy to provide virtual care (A is best), and which make it difficult (I'm not sure what the * means):
Aside from that, the course touts the virtues of virtual care, claiming that in some ways, it's superior to in-person care, and giving examples, such as the fact that patients have quicker access to virtual care. They also claim that many, if not most, common complaints can be treated virtually, and a lot of monitoring can be done at a distance, e.g. glucose. In addition, they mention the use of wearable devices for tracking activity, etc., and the up and coming virtual examination tools, like stethoscopes.
The video is careful to note situations which require in-person treatment, such as a wheezing infant, or chest and jaw pain in a 68 year old man.
A bit comical were the presentations. For a company that's promoting care via video-conferencing, they should probably have gotten better people to present in their video. One guy had shifty eyes, another had drooping eyelids and looked like he was falling asleep and forgetting what he needed to say, yet another guy looked like his shoulders were hiked up to the point of having no neck.
While I definitely prefer in-person work, I can see where psychiatry, and especially psychotherapy, are amenable to virtual care, probably more-so than specialties that require a physical examination. But given the regulatory and legal limitations, I'm not ready to go there, yet.
I was curious about the progress in this field, so I did take the course, and am now officially certified. I also accidentally clicked an "okay" button, thinking it would allow me to print out my certificates. But it was the wrong button. The button I wanted said, "certificate only", but I didn't see it in time. The "okay" button indicated that I was allowing myself to be part of the HealthTap network of physicians. I didn't really want that, but I suppose it doesn't matter since I'm not going to do anything with it. So watch out for this if you decide to try it.
What I was mainly interested in, in the course, were the legal and regulatory issues related to virtual care. And I did learn a couple things. For instance, you do need to be licensed in your patient's state in order to provide virtual care. I don't know if that means the state where the patient resides, or just the state the patient is in when seeing you. I would guess the latter, since I can treat patients, in person, who live in neighboring New Jersey or Connecticut for example, where I'm not licensed, as long as they see me in my New York office.
Incidentally, you don't need to be licensed in any particular state to virtually treat patients outside the US.
The course referenced the Interstate Medical Licensure Compact, which, "Creates a new pathway to expedite the licensing of physicians seeking to practice medicine in multiple states. States participating in the Compact agree to share information with each other and work together in new ways to significantly streamline the licensing process."
A number of states have already enacted legislature that will allow this expedited pathway to proceed, and other states have introduced such legislation. Still others, such as New York, have done neither. One interesting point I noted is that in order to use this expedited system, you need to be primarily licensed in a state that has already enacted the legislature. So if I want to virtually care for patients in Montana, which has enacted this legislature, I can't, because I'm licensed in New York, which hasn't.
That point is irrelevant, though, since there is currently no administrative process for applying for this pathway, although they state that there, "...will be soon."
The video mentioned that there are CPT codes for virtual care, ranging from 99441 for a 5-10 minute telephone Eval/Management consultation, to a 99444 for an online E/M, to a 99446 inter-professional 5-10 minute consult, to a 99490 > 20 minutes of chronic care management. But most virtual care billing is done using the same CPT codes that would be used for a regular office visit, with a GT modifier, e.g. 99213 GT.
Most importantly, 25 states with parity laws, plus Washington DC, have enacted "...legislation requiring private insurers to pay for Virtual Care at the same level as equivalent in-person services, provided the care is deemed medically necessary."
According to this document, in New York, "The law requires telehealth parity under private insurance, Medicaid, and state employee health plans. The law does restrict the patient setting as a condition of payment."
This image depicts which states make it easy to provide virtual care (A is best), and which make it difficult (I'm not sure what the * means):
Aside from that, the course touts the virtues of virtual care, claiming that in some ways, it's superior to in-person care, and giving examples, such as the fact that patients have quicker access to virtual care. They also claim that many, if not most, common complaints can be treated virtually, and a lot of monitoring can be done at a distance, e.g. glucose. In addition, they mention the use of wearable devices for tracking activity, etc., and the up and coming virtual examination tools, like stethoscopes.
The video is careful to note situations which require in-person treatment, such as a wheezing infant, or chest and jaw pain in a 68 year old man.
A bit comical were the presentations. For a company that's promoting care via video-conferencing, they should probably have gotten better people to present in their video. One guy had shifty eyes, another had drooping eyelids and looked like he was falling asleep and forgetting what he needed to say, yet another guy looked like his shoulders were hiked up to the point of having no neck.
While I definitely prefer in-person work, I can see where psychiatry, and especially psychotherapy, are amenable to virtual care, probably more-so than specialties that require a physical examination. But given the regulatory and legal limitations, I'm not ready to go there, yet.
Saturday, January 11, 2014
A New Low
Just when you thought it was safe to have health insurance... I mean, there's the Affordable Care Act, that at least makes it impossible for insurance companies not to insure you if you have a pre-existing condition, even if there are tons of problems with the Act. And there's the Mental Health Parity thing. You'd think that would provide some protection.
Skeptical by nature, I assumed insurance companies would come up with new and interesting ways to bite. And they have not disappointed.
A patient of mine submitted a claim a while back. A couple months later, when it wasn't reimbursed, the patient followed up, and sure enough, the insurance company had no record of the claim. (I happen to know that the claim was submitted properly). The patient re-submitted the claim, and the insurance company's response was that it was submitted too late, so they wouldn't reimburse. (I think there's a similar joke about a dry cleaner).
The patient appealed. Forms were filled out. Phone calls were made. More forms were filled out.
And now, another form needs to be filled out to "justify" out-of-network services, even though the appeal is about the supposedly late submission of the claim. My job, in this, is to cite two examples in "the literature" explaining why the patient requires out-of-network services.
When I learned this, my first thought was, "How am I supposed to come up with that?" But after some thought, I decided there are a couple arguments to be made, characterized by certain lines of inquiry.
1. Continuity of Care-do patients fare better when they don't switch providers?
2. Therapeutic Alliance-related to continuity of care, but also different, since it is possible to continue care with someone with whom you have a poor therapeutic alliance.
And there's an uncomfortable "3", which is, "Do patients actually have better outcomes with out-of-network providers, and if so, why?" Related to this is, "Are there discernible differences between providers who accept insurance, and those who don't?"
So I thought I'd make lemonade and post about researching these ideas. I'd prefer sparkling limeade with coconut, but we're talking insurance companies here.
I searched, "continuity of care psychiatry", and got a bunch of links. And then I got more links from those links. Some of the articles were about defining the meaning of continuity of care. Others seemed to just assume that continuity of care was a good thing.
There was a reference to the National Service Framework for Mental Health, which is a 2001 Department of Health document from the UK, too long for me to read in full, but the source I got it from (can't remember) claimed that it recommends continuity of care as essential.
Here's more:
Intensity and Continuity of Services and Functional Outcomes in the Rehabilitation of Persons with Schizophrenia
Clients who...had fewer gaps in service delivery achieved greater rehabilitative improvement in social, work, and independent living domains and had fewer days of hospitalization.
Another article that seems critical is:
Tessler RC. Continuity of care and client outcome. Psychosocial Rehabilitation Journal 1987; 11(1):39-53.
Unfortunately, I couldn't track it down online. Not even the abstract.
There's what looks to be a not-quite-on-my-target paper, Continuity of care in mental health: understanding and measuring a complex phenomenon, but the bibliography is promising.
I found this article in the "continuity of care" search:
Therapeutic Alliance and Psychiatric Severity as Predictors of Completion of Treatment for Opioid Dependence
among patients with moderate to severe psychiatric problems, less than 25 percent with weak therapeutic alliances completed treatment, while more than 75 percent with strong therapeutic alliances completed treatment...In this patient subgroup, a strong therapeutic alliance may be an essential condition for successful treatment.
Next I searched, "therapeutic alliance and treatment outcome."
I found this article in JAMA Psychiatry:
The Role of the Therapeutic Alliance in the Treatment of Schizophrenia
Relationship to Course and Outcome
This study examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients with nonchronic schizophrenia... Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not.
And this one from J consult Clin Psychol:
The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression.
This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients...A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP (cognitive behavioral analysis system of psychotherapy) and BSP (brief supportive psychotherapy),...p < .001.
Then there's the psychoanalytic literature. There are a ridiculously large number of hits for "therapeutic alliance" and "analytic dyad", but they're mostly about the meaning and development of those elements. It's axiomatic that a good alliance is a necessary part of any treatment.
I also searched "discontinuity in psychiatric care", and mostly I got measurements-e.g. how many new patients in a clinic drop out of treatment. They didn't seem to address the problem of what happens to patients when they stop treatment, or switch treatment providers.
I searched:
"patient outcomes in psychiatric clinics with frequent change in providers"
"Do psychiatric patients get worse when they switch providers"
"Do psychiatric patients drop out of treatment when they switch providers"
Nothing came up that seemed to address what typically happens in an outpatient clinic, where there's resident turnover every year, and what that does to patients, which is what I was hoping to find with those searches.
Now on to point "3", patient outcomes with out of network vs. in network psychiatrists. That search came up with things like, "benefits of antidepressants" and "Providers are responsible for the correct submission of claims", under OUTreach...Network.
One thing we do know is that fewer psychiatrists than doctors of other stripes accept private insurance:
The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% ...vs 88.7% ... P < .001) and had declined by 17.0% since 2005-2006.
But what are the differences between shrinks who decide to join an insurance network, and those who don't? And whose patients do better? I wonder if the study's been done. And if it hasn't, someone should do it, because the results are not simply academic.
Saturday, November 9, 2013
MHPAEA Addendum
Yesterday, in Parity or Parody, I posted about the new rules for the Mental Health Parity and Addiction Equity Act (MHPAEA).
A later article in the NY times, Equal Coverage for the Mentally Ill, states that, in fact, insurers ARE required to offer Mental Health and Substance (MH/Sub) coverage. This is not consistent with the government sites I referenced (DOL, CMS), but perhaps those sites hadn't been updated yet to reflect the new rules.
Regardless, I maintain that the excessively complicated details of the Act will make it possible for insurance companies to continue to restrict coverage for MH/Sub care.
I was struck by one paragraph, in particular, in the article:
The effect on costs is uncertain. Insurers fear that the expenses of high-cost inpatient treatment or long-term rehabilitation of patients suffering from mental health disorders or substance abuse will drive up insurance costs, but experts say the number of people receiving high levels of care will be too small to have a significant effect on overall costs. And in the long run, better care could cure enough people to save billions of dollars a year in medical costs, lost wages and reduced productivity associated with alcoholism and other addictions.
Who are we "saving billions" for? The article seems to make the assumption that the interests of insurance companies coincide with those of the government, and the people. Myself, I don't believe insurers care about lost wages and reduced productivity, especially if it means a dent in their bottom line.
And I don't even know where to start with the phrase, "Better care could cure enough people to save billions of dollars a year." Key words here include "could", "cure", and "better".
(Here's a link to the Final Rule. Good luck reading it.)
A later article in the NY times, Equal Coverage for the Mentally Ill, states that, in fact, insurers ARE required to offer Mental Health and Substance (MH/Sub) coverage. This is not consistent with the government sites I referenced (DOL, CMS), but perhaps those sites hadn't been updated yet to reflect the new rules.
Regardless, I maintain that the excessively complicated details of the Act will make it possible for insurance companies to continue to restrict coverage for MH/Sub care.
I was struck by one paragraph, in particular, in the article:
The effect on costs is uncertain. Insurers fear that the expenses of high-cost inpatient treatment or long-term rehabilitation of patients suffering from mental health disorders or substance abuse will drive up insurance costs, but experts say the number of people receiving high levels of care will be too small to have a significant effect on overall costs. And in the long run, better care could cure enough people to save billions of dollars a year in medical costs, lost wages and reduced productivity associated with alcoholism and other addictions.
Who are we "saving billions" for? The article seems to make the assumption that the interests of insurance companies coincide with those of the government, and the people. Myself, I don't believe insurers care about lost wages and reduced productivity, especially if it means a dent in their bottom line.
And I don't even know where to start with the phrase, "Better care could cure enough people to save billions of dollars a year." Key words here include "could", "cure", and "better".
(Here's a link to the Final Rule. Good luck reading it.)
Friday, November 8, 2013
Parity or Parody?
An article in the Times, Rules to Require Equal Coverage for Mental Ills.
Okay, so there's "parity". What does that boil down to, and what problems can we foresee?
This is the very brief description of the Mental Health Parity and Addiction Equity Act from the Department of Labor site:
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. MHPAEA supplements prior provisions under the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits.
I tried to read a little about the details of the Act, but it wasn't easy. From what I could glean, from the DOL site, as well as CMS, there's good news and there's bad news.
The good news:
-The criteria and standards for medical necessity determinations must be made available upon request
-Ditto the reason for a denial
-There can't be a separate deductible for Med/Surg and Mental Health/Substance; they need to be combined.
-There were already parity requirements in place with respect to aggregate lifetime and annual dollar limits, but these now apply to Substance treatment
-If your plan covers Out-of-Network providers for med/surg, it needs to cover out-of-network for MH/Sub.
The bad and confusing news:
-The Act does not mandate that a plan provide MH/SUD benefits.
-The Act does not apply to issuers who sell health insurance policies to employers with 50 or fewer employees or who sell health insurance policies to individuals.
-The regulations provide that the “predominant/substantially all” test applies to six classifications of benefits on a classification-by-classification basis. The regulation also includes other rules and definitions that are necessary in order for plans, issuers and their advisers to apply this general parity test.
This is where it starts to careen off into the stratosphere. I truly don't get the test and classifications, but I'll share the little bits and pieces that I partially grasp.
The general rule is that a plan may not impose a financial requirement or quantitative treatment limitation applicable to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or quantitative limitation of that type applied to substantially all medical/surgical benefits in the same classification.
The six classifications of benefits are:
Inpatient in-network;
Inpatient out-of-network;
Outpatient in-network;
Outpatient out-of-network;
Emergency care;
Prescription drugs.
Examples of financial requirements are copays, deductibles, and out of pocket maximums. Examples of quantitative treatment limitations are number of visits and days of coverage.
There are also Non-Quantitative treatment limitations, including medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, plan methods for determining usual, customary, and reasonable charges, refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols), and exclusions based on failure to complete a course of treatment.
The test for determining parity refers to levels of types of financial requirements or treatment limitations. The level of a type of financial requirement or treatment limitation refers to the magnitude of the type of financial requirement or treatment limitation. For example, different levels of coinsurance include 20% and 30%, different levels of copays include $15 and $20, or different levels of an episode limit include 21 inpatient days per episode and 30 inpatient days per episode.
To determine if a quantitative financial requirement (such as a copay) or quantitative treatment limitation (such as a visit limit) is permissible, the parity analysis must be applied for that type of financial requirement or treatment limitation within a coverage unit for each of the six classifications of benefits separately. A coverage unit refers to the way in which a plan groups individuals for purposes of determining benefits, or premiums or contributions (for example, self-only, family, employee plus spouse).
If a type of financial requirement or quantitative treatment limitation applies to substantially all medical/surgical benefits in a classification (for example, if a copay applies to substantially all medical/surgical benefits), then it may be permissible for that requirement or limitation (the copay) to apply to mental health or substance use disorder benefits. Generally, a financial requirement or treatment limitation is considered to apply to substantially all medical/surgical benefits if it applies to two-thirds or more of the medical/surgical benefits for the same classification and coverage unit.
The predominant level of a type of requirement or limitation applicable to medical/surgical benefits within a classification is the most restrictive level of the requirement or limitation that can be imposed on mental health or substance use disorder benefits within that classification...If, for example, for self-only coverage a $10 copay is the predominant level of copay that applies to substantially all inpatient in-network medical/surgical benefits, that is the most restrictive copay that can apply to inpatient in-network mental health or substance use disorder benefits.
A plan may not create sub-classifications for generalists and specialists to determine separate predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits. However, if the predominant level of a type of financial requirement that applies to substantially all medical/surgical benefits in a classification is the one charged for a medical/surgical specialist, then that “specialist” financial requirement can be applied for all mental health or substance use disorder benefits within that classification. On the other hand, if the predominant level of a type of financial requirement that applies to substantially all medical/surgical benefits in a classification is the one charged for a medical/surgical generalist, then the financial requirement charged for all mental health or substance use disorder benefits within that classification cannot be higher than the “generalist” financial requirement for medical/surgical benefits.
Oy.
Let's try this. A patient comes to see me. I'm classified as Outpatient, Out-Of-Network. The patient is single, so that's a self-only coverage unit. He is also diabetic, and his endocrinologist is also out-of network. His insurance pays 80% (the financial requirement) of the usual and customary fee (the non-quantitative treatment limitation) for endocrinologists in his region, and he is responsible for the rest. That's the level of coverage. And the percentage payment is the type of financial requirement (as opposed to if he had to pay a copay).
But two thirds of self-only covered patients in the region who are treated by endocrinologists have out of network coverage (in that plan or a different one?) that pays only 70% of the usual and customary fee, making 70% the most restrictive level of requirement. So when he submits my bill to his insurance, he will only be reimbursed 70% of the usual and customary fee. (Is this the customary fee for psychiatrists, or endocrinologists?) And if 2/3 of coverage for endocrinologists is at the 70% rate, but 2/3 of coverage for all outpatient treatment is at an 80% rate, then my bill will be reimbursed at the 80% rate.
Well, I'm glad we cleared that up.
I'm wondering if the upshot will be that MH/Sub just stops being covered. Period. There's no requirement for an insurer to cover it. The MHPAEA only requires that if it's covered, it has to be covered with parity, as defined in the very complicated details that I don't understand.
Moreover, it's obvious that insurance companies will find ways to apply these byzantine rules to their advantage.
The real twister here is that we're comparing apples and kumquats. I'm not referring to the question of whether psychiatry is a "medical" endeavor. I'm only considering the type, and more importantly, frequency, of treatment used in psychiatry, vs. say, cardiology (that would be a level of treatment, and a quantitative treatment limitation).
Admittedly, I'm an anomaly, because I see some patients as frequently as 4 times per week in psychoanalysis (more on this in a future post). I don't think patients visit their cardiologists 4 times per week over the course of a number of years. So does "no more restrictive" mean that my patients will be covered for as many visits per year as they would make to a cardiologist, assuming they needed one?
"Because of the MHPAEA, we are only required to cover you for a maximum of 4 sessions per year, rather than our previous cap of 40 sessions per year, because you see your cardiologist 4x/year."
What a windfall for the insurance companies. Remind me to buy stock in United healthcare.
And don't forget to join POLL, our Psychiatry Online Lifelong Learning journal club over on LinkedIn.
Okay, so there's "parity". What does that boil down to, and what problems can we foresee?
This is the very brief description of the Mental Health Parity and Addiction Equity Act from the Department of Labor site:
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. MHPAEA supplements prior provisions under the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits.
I tried to read a little about the details of the Act, but it wasn't easy. From what I could glean, from the DOL site, as well as CMS, there's good news and there's bad news.
The good news:
-The criteria and standards for medical necessity determinations must be made available upon request
-Ditto the reason for a denial
-There can't be a separate deductible for Med/Surg and Mental Health/Substance; they need to be combined.
-There were already parity requirements in place with respect to aggregate lifetime and annual dollar limits, but these now apply to Substance treatment
-If your plan covers Out-of-Network providers for med/surg, it needs to cover out-of-network for MH/Sub.
The bad and confusing news:
-The Act does not mandate that a plan provide MH/SUD benefits.
-The Act does not apply to issuers who sell health insurance policies to employers with 50 or fewer employees or who sell health insurance policies to individuals.
-The regulations provide that the “predominant/substantially all” test applies to six classifications of benefits on a classification-by-classification basis. The regulation also includes other rules and definitions that are necessary in order for plans, issuers and their advisers to apply this general parity test.
This is where it starts to careen off into the stratosphere. I truly don't get the test and classifications, but I'll share the little bits and pieces that I partially grasp.
The general rule is that a plan may not impose a financial requirement or quantitative treatment limitation applicable to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or quantitative limitation of that type applied to substantially all medical/surgical benefits in the same classification.
The six classifications of benefits are:
Inpatient in-network;
Inpatient out-of-network;
Outpatient in-network;
Outpatient out-of-network;
Emergency care;
Prescription drugs.
There are also Non-Quantitative treatment limitations, including medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, plan methods for determining usual, customary, and reasonable charges, refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols), and exclusions based on failure to complete a course of treatment.
The test for determining parity refers to levels of types of financial requirements or treatment limitations. The level of a type of financial requirement or treatment limitation refers to the magnitude of the type of financial requirement or treatment limitation. For example, different levels of coinsurance include 20% and 30%, different levels of copays include $15 and $20, or different levels of an episode limit include 21 inpatient days per episode and 30 inpatient days per episode.
To determine if a quantitative financial requirement (such as a copay) or quantitative treatment limitation (such as a visit limit) is permissible, the parity analysis must be applied for that type of financial requirement or treatment limitation within a coverage unit for each of the six classifications of benefits separately. A coverage unit refers to the way in which a plan groups individuals for purposes of determining benefits, or premiums or contributions (for example, self-only, family, employee plus spouse).
If a type of financial requirement or quantitative treatment limitation applies to substantially all medical/surgical benefits in a classification (for example, if a copay applies to substantially all medical/surgical benefits), then it may be permissible for that requirement or limitation (the copay) to apply to mental health or substance use disorder benefits. Generally, a financial requirement or treatment limitation is considered to apply to substantially all medical/surgical benefits if it applies to two-thirds or more of the medical/surgical benefits for the same classification and coverage unit.
The predominant level of a type of requirement or limitation applicable to medical/surgical benefits within a classification is the most restrictive level of the requirement or limitation that can be imposed on mental health or substance use disorder benefits within that classification...If, for example, for self-only coverage a $10 copay is the predominant level of copay that applies to substantially all inpatient in-network medical/surgical benefits, that is the most restrictive copay that can apply to inpatient in-network mental health or substance use disorder benefits.
A plan may not create sub-classifications for generalists and specialists to determine separate predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits. However, if the predominant level of a type of financial requirement that applies to substantially all medical/surgical benefits in a classification is the one charged for a medical/surgical specialist, then that “specialist” financial requirement can be applied for all mental health or substance use disorder benefits within that classification. On the other hand, if the predominant level of a type of financial requirement that applies to substantially all medical/surgical benefits in a classification is the one charged for a medical/surgical generalist, then the financial requirement charged for all mental health or substance use disorder benefits within that classification cannot be higher than the “generalist” financial requirement for medical/surgical benefits.
Let's try this. A patient comes to see me. I'm classified as Outpatient, Out-Of-Network. The patient is single, so that's a self-only coverage unit. He is also diabetic, and his endocrinologist is also out-of network. His insurance pays 80% (the financial requirement) of the usual and customary fee (the non-quantitative treatment limitation) for endocrinologists in his region, and he is responsible for the rest. That's the level of coverage. And the percentage payment is the type of financial requirement (as opposed to if he had to pay a copay).
But two thirds of self-only covered patients in the region who are treated by endocrinologists have out of network coverage (in that plan or a different one?) that pays only 70% of the usual and customary fee, making 70% the most restrictive level of requirement. So when he submits my bill to his insurance, he will only be reimbursed 70% of the usual and customary fee. (Is this the customary fee for psychiatrists, or endocrinologists?) And if 2/3 of coverage for endocrinologists is at the 70% rate, but 2/3 of coverage for all outpatient treatment is at an 80% rate, then my bill will be reimbursed at the 80% rate.
Well, I'm glad we cleared that up.
I'm wondering if the upshot will be that MH/Sub just stops being covered. Period. There's no requirement for an insurer to cover it. The MHPAEA only requires that if it's covered, it has to be covered with parity, as defined in the very complicated details that I don't understand.
Moreover, it's obvious that insurance companies will find ways to apply these byzantine rules to their advantage.
The real twister here is that we're comparing apples and kumquats. I'm not referring to the question of whether psychiatry is a "medical" endeavor. I'm only considering the type, and more importantly, frequency, of treatment used in psychiatry, vs. say, cardiology (that would be a level of treatment, and a quantitative treatment limitation).
Admittedly, I'm an anomaly, because I see some patients as frequently as 4 times per week in psychoanalysis (more on this in a future post). I don't think patients visit their cardiologists 4 times per week over the course of a number of years. So does "no more restrictive" mean that my patients will be covered for as many visits per year as they would make to a cardiologist, assuming they needed one?
"Because of the MHPAEA, we are only required to cover you for a maximum of 4 sessions per year, rather than our previous cap of 40 sessions per year, because you see your cardiologist 4x/year."
What a windfall for the insurance companies. Remind me to buy stock in United healthcare.
And don't forget to join POLL, our Psychiatry Online Lifelong Learning journal club over on LinkedIn.
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