[NYAPRS Enews] MHW: Field To Address Scope Of Services, Care Issues In New Parity Regulations

[Harvey Rosenthal]

NYAPRS Note: NYAPRS is pleased to include a panel discussion entitled
Washington Report: National Healthcare and Medicaid Reform at our
upcoming April 21-2 Annual Executive Seminar on Systems Transformation
that will include a discussion of the anticipated impact of implementing
new federal parity regulations. The panel will feature Charles Ingoglia,
Vice President Public Policy and Technical Assistance at the National
Council for Community Behavioral Healthcare and Allison Wishon
Siegwarth, Policy Associate at the Bazelon Center for Mental Health Law.
For more details, please go to www.nyaprs.org 

 

 

MH Field To Address Scope Of Services, Care Issues In New Parity
Regulations

Mental Health Weekly  February 8, 2010

 

The federal government last week published its interim final rules for
parity implementation much to the relief of the mental health community
who contend that while the rules are consistent with the intent of the
law, some clarification is still needed, particularly on continuum of
care and medical management issues.

 

The U.S. Departments of Health and Human Services, Labor and Treasury
published the 43-page document to implement the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008 on Feb.
2.

 

The interim final rule (IFR), slated to go into effect on April 5, will
apply to group health plans and health insurance issuers for plan years
beginning on or after July 1, 2010. The departments are encouraging
public comments on whether and to what extent the parity law addresses
the scope of services or continuum of care provided by insurance plans.
Public comments on the IFR will be accepted through May 3, 2010.

 

According to the regulation, comments from the public submitted last
year agreed that the statute should be applied within several broad
classifications of benefits. The six classifications are:

1. Inpatient, in-network.

2. Inpatient, out-of-network.

3. Outpatient, in-network.

4. Outpatient, out-of-network.

5. Emergency care.

6. Prescription drugs.

 

According to the regulations, if a plan provides mental health and
substance use   benefits, these benefits must be provided at parity with
the medical/surgical benefits provided in that classification.

 

"Overall, we are very pleased the regulations are out. We think the
departments did a very good job preserving the intent of the law and we
look forward to working with them on implementing the parity law,"
Jennifer Tassler, J.D., deputy director for regulatory affairs at the
American Psychiatric Association (APA), told MHW.

 

Tassler noted that additional guidance on how parity will apply to
Medicaid managed care will be released at some point by the Department
of Health and Human Services. "We do have concerns that the regulations
do not cover Medicaid managed care plans," Tassler said. While the
parity law applies to Medicaid, the Department of Health and Human
Services is expected to release at some point, additional guidance on
how parity will apply to Medicaid managed care.

 

Tassler added, "It's a source of confusion. Our concern is that the
Medicaid managed plans should be applied equally. It doesn't make sense
to have two different standards."

 

Treatment Limitations

The IFR creates a new category that the parity requirement applies to
called "nonquantitative treatment limitations." The IFR distinguishes
between two types of limits on services: quantitative limits which refer
to for example, limits on dollar amounts and the number of sessions, and
"non-quantitative limits."

 

The regulations prohibits plans from using the following
non-quantitative limits, unless similar restrictions exist for
medical/surgical benefits: medical management, prior authorization,
prescription formulary design, and "fail-first" or step therapies. 

 

"We think the way the regulations have addressed quantitative and
nonquantitative treatment limits to establish standards makes it very
clear that behavioral health has to be treated in the same way," Chuck
Ingoglia, vice president of public policy for the National Council for
Community Behavioral Healthcare, told MHW. 

 

"In the past, plans used medical management criteria to limit access to
treatment." Ingoglia added, "If you don't have comparative standards on
medical/surgical benefits, you can't have more stringent standards on
mental health and substance abuse."

 

Ingoglia said the National Council is going to be interested in seeing
the guidance come out on Medicaid managed care. "So many people our
members serve are covered by Medicaid," he said.

 

'Conflicting Messages'

The managed behavioral health care companies that make up the
Association for Behavioral Health and Wellness (ABHW) said the
regulations are broader than the intent of the legislative language. "We
were surprised to see the expansive nature of the regulations; it covers
health plan operations when the focus of the legislative language was on
benefit limitations," ABHW president and CEO Pamela Greenberg, told MHW.

 

The regulations also provide some conflicting messages, she said. "For
example, the interim final regulation has an entire section that
discusses the literature on the benefits

of managed care and ability of managed care to make parity affordable
yet the specifics of the IFR impede some of the tools that managed care
employs to contain costs and promote quality," Greenberg said.

 

Greenberg added, "At this point we are still reviewing and trying to
interpret the regulations and hoping to get some clarification,
especially in the area of the newly established term, 'nonquantitative
treatment limitation.' Our initial reaction is that the implementation
of these regulations will have cost implications in excess of the
estimated 1 percent or less increase."

 

A parity standard is difficult to apply when it comes to medical
management as diagnoses are treated differently in both medical and
behavioral health. The cost estimates for the legislation were based on
the notion that the benefit would be managed in the way it currently is
managed, said Greenberg. "The interim final regulations alter the way
the benefit can be managed and putting additional, unanticipated
requirements on the plans will most likely have cost implications that
were not considered by the initial cost estimates," she said.

 

Remaining Issues

Regulatory issues, such as the continuum of care will also need to be
addressed, said Debra Wentz, Ph.D., president and CEO of the New Jersey
Association of Mental Health Agencies, Inc. (NJAMHA).

 

The parity regulations do not yet specifically require that individuals
be provided the standard form of treatment needed when there is not a
comparable level of care for medical issues, she said.

 

"For example, if an individual requires counseling or non-hospital
residential treatment, but there is no comparable treatment for a
physical ailment, those critical services should still be covered," said
Wentz, pointing out that the regulations did not resolve the issue. "The
purpose of the law is to improve access, and every detail of the
regulations must explicitly support this purpose."

 

Another critical issue involves the need to ensure a sufficient number
of providers participating in insurance plans, Wentz noted. "Of course,
we fully support the intent of the parity legislation, but it will not
be successful - and children and adults with behavioral healthcare needs
will continue to struggle - if there are not enough providers to serve
them," she said. The regulations must require insurance networks to
enroll an adequate number of participating behavioral healthcare
providers, Wentz added. 

 

For more information about submitting comments, the interim final
regulations can be accessed at:
http://edocket.access.gpo.gov/2010/pdf/2010-2167.pdf.

 

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