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MHAMD Maryland Parity Project and Network Adequacy Report Howard County Behavioral Health Task Force February 12, 2015.

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Presentation on theme: "MHAMD Maryland Parity Project and Network Adequacy Report Howard County Behavioral Health Task Force February 12, 2015."— Presentation transcript:

1 MHAMD Maryland Parity Project and Network Adequacy Report Howard County Behavioral Health Task Force February 12, 2015

2 Adrienne Ellis, Director, Maryland Parity Project - Mental Health Association of Maryland, with grant funding created a project to: – Educate consumers and providers to their rights – Offer case assistance to consumers who have been inappropriately denied treatment @marylandparity on Twitter

3 Qualified Health Plans Essential Health Benefits Adequate Networks Mental Health and Substance Use Disorder Parity

4 Preventive Screening Outpatient Intensive Outpatient Partial Hospitalization Residential Treatment (Rehab) Inpatient (Detox) The Behavioral Health Benefit Qualified Health Plans * Also includes crisis services and prescription drugs

5 Qualified Health Plan Requirements Certified by Maryland Health Benefit Exchange upon review by Maryland Insurance Administration: – Adequate number of providers in each network, including MH/SUD providers – Must contract with Essential Community Providers in adequate numbers to serve medically underserved populations – Must comply with Federal Parity Act – Will provide continuity of care provisions

6 Network Adequacy Study on 2014 Qualified Health Plans Carefirst Evergreen United Kaiser More than 5000 calls from June – Nov 2014 Used CRISP Provider Search tool provided by Maryland Health Connection 1154 total psychiatrists listed


8 Study Results – Only 43% of psychiatrists could be reached – Almost 20% reached were NOT psychiatrists – Less than 40% were psychiatrists who were accepting the insurance – Only 18% were accepting insurance AND accepting new outpatients – Less than 14% were accepting insurance and available for appointment in less than 45 days


10 Recommendations Insurance carriers make public a self-audit of the QHPs yearly Insurance carriers make available their out of network exemption process The Maryland Insurance Administration publish the out of network exemption information, including on their complaint form.

11 What Does Parity Mean? Fewer Barriers - If MH/SUD benefits are covered in the plan, treatment limitations and financial requirements cannot be separate from or more restrictive than those governing medical/surgical benefits. Patients get appropriate care - Scope of services must be comparable to medical services - Regulation of plan features that limit access to MH/SUD care Providers get equitable payment

12 Benefit Classifications In Network InpatientOutpatient Out of Network InpatientOutpatient Other Emergency Care Prescription Drugs *If a plan offers MH/SUD benefits in ANY of the 6 categories, it must offer it in all categories in which it provides med/surg benefits.

13 Limitations and Restrictions Not Separate From or More Restrictive Than for Somatic Care Quantitative No More Restrictive Than the Predominant Requirement/Limitation Applied to Substantially All Med/Surg Benefits In the Category - Deductibles -Co-payments -Visit Limits -Day Limits NonQuantitative Must be Comparable and No More Stringent Than Application to Med/Surg Benefits in the Category -Medical necessity criteria -Authorization requirements -Credentialing standards Reimbursement rates

14 Disclosure of Plan Information Medical Necessity Criteria – MH/SUD criteria must be made available to both current or potential participant, beneficiary or contracting provider upon request Plan criteria for MH/SUD and M/S benefits are “plan” documents that must be furnished within 30 days of request for ERISA-governed plans. -- Includes plan standards for applying all NQTLs Denials of Reimbursement and Payment – Reason for denial of reimbursement or payment for MH/SUD benefits available upon request to participant or beneficiary – Internal review and external appeal regulations set out information required and timeframes

15 Recommendations 2015 Parity Legislation Introduced Would Require: – carriers to demonstrate they comply with the law for both quantitative and nonquantitative treatment limitations – Carriers to file report and supporting documents with the Maryland Insurance Administration

16 Resources You Can Use Maryland – Health Benefit Exchange – Maryland Health Connection – Department of Health and Mental Hygiene – Mental Health Association of Maryland – Parity Project – Drug Policy Clinic, University of Maryland Carey School of Law, contact – Maryland Women’s Coalition for Health Care Reform Federal – Department of Health & Human Services 16

17 Adrienne Ellis, Director, Maryland Parity Project - @marylandparity on Twitter Contact Information

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