The Federal Parity Law March 21, 2017

The Federal Parity Law March 21, 2017
Accessing Insurance Coverage for Substance Use & Mental Health Treatment The Federal Parity Law March 21, 2017

Karla Lopez, Esq. Senior Staff Attorney Legal Action Center
Who Is Your Presenter? Karla Lopez, Esq. Senior Staff Attorney Legal Action Center

Who Is the Legal Action Center?
Non-profit law & policy organization Anti-discrimination & privacy work Substance Use Disorders HIV/AIDS Criminal Records Legal services, litigation, policy, technical assistance

Help from Legal Action Center
Our website has many resources Call (providers & advocates) for info on: Health insurance for substance use disorders (SUD) Privacy or discrimination relating to HIV/AIDS, SUD, or criminal records (212) Refer clients See next slide….

Help from Legal Action Center
We provide free legal services, including: Assistance with HIV testing & confidentiality Assistance with claims of discrimination based on: HIV status History of substance use disorder Criminal record: Rap sheet review & error correction Certificates of Relief & Good Conduct Job & housing discrimination

Today’s Training Explains the federal parity law Tells NYS service providers and advocates how they can take advantage of their rights, and the rights of their clients/patients, under the federal parity law Provides a brief overview of relevant NY state laws

Get Credit for your Attendance!
HAVE YOU REGISTERED? If you haven’t officially registered with the NYS Department of Health AIDS Institute, please do it now: If you need assistance, contact Vanessa Severino at

Today’s Handouts This PowerPoint
LAC’s “Health Insurance for Addiction & Mental Health Care: A Guide to the Federal Parity Law” NY Insurance Circular Letters: No. 20 (2009), No. 5 (2014), No. 6 (2015), No. 4 (2016), No. 6 (2016) Summaries of NY Attorney General parity settlements Letter from NYS DOH re: overdose prevention program (9/11/2014)

Additional Resources LAC Parity Resources: use-resources/parity-health-care-access-resources/ Federal govt. resources: Parity Implementation Coalition: Coalition for Whole Health: Parity Track:

Audience Poll

POLL Do you work with clients/patients who have substance use or mental disorders? Yes No

POLL Have you noticed your patients/clients having more difficulty getting insurance coverage for substance use disorder or mental health treatment than for other kinds of medical and surgical care? Yes No Don’t know/can’t answer

POLL How familiar are you with the federal parity law?
I’ve never heard of it I’ve heard of it but don’t know much about it I know a lot about it

What is the Federal Parity Law?
Overview Who must comply What does it require The details

What Is the Federal Parity Law? 1. Overview
Parity Guide, p. 6

Federal Parity Law: Overview
The Paul Wellstone & Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA or “federal parity law”) Passed in 2008, after 12 years of advocacy Congress: purpose of federal parity law is “to counter a history of discrimination and stigma against mental illness and substance-related disorders that has resulted in much less access to care.”

The federal parity law requires health insurance plans that cover mental health (MH) & substance use disorder (SUD) benefits to cover them equally (at “parity”) with other medical & surgical benefits

This means that it should no longer be more difficult for a patient to have her addiction treatment covered by her health insurance than to have her diabetes treatment covered.

Note on State Law: Many states have their own parity laws, including NY Today’s webinar will focus on the federal parity law, which applies to every state in the country NY also passed packages of laws in 2014 & 2016 in response to the opioid crisis.

What Is the Federal Parity Law? 2. Who Must Comply?
Parity Guide, p. 10

Federal Parity Law: Who Must Comply?
All public and private health insurance except: Medicare Traditional (fee-for-service) Medicaid Plans that have successfully applied for a cost-increase exemption (don’t know of any in NYS) “Grandfathered” small group (< 51) plans offered outside the NY State of Health marketplace (very few exist) Retiree-only plans TriCare (but other federal regulations) Plans that choose to opt out (church-sponsored, “self-insured” state/local government)

So, who does have to comply? Large group health plans (i.e., plans offered by private employers with 51+ employees) Medicaid Managed Care plans and Alternative Benefit Plans (ABPs) Children’s Health Insurance Program (CHIP) Individual plans Most small group (less than 51 people) plans Most state & local govt. employer plans Federal government plans Most church-sponsored plans Grandfathered individual plans aren’t required to comply with parity, but very few (if any) grandfathered individual plans exist. Same goes for small group plans.

For help determining type of health plan, see “How to Determine Your Type of Health Insurance Plan” on p. 25 of Health Insurance for Addiction & Mental Health Care: A Guide to the Federal Parity Law Grandfathered individual plans aren’t required to comply with parity, but very few (if any) grandfathered individual plans exist. Same goes for small group plans. Parity Guide, p. 25

Confused about what some of these terms mean? Check out the Parity Guide’s Glossary, on p. 53 Grandfathered individual plans aren’t required to comply with parity, but very few (if any) grandfathered individual plans exist. Same goes for small group plans. Parity Guide, p. 53

Note on federal parity law & ACA The federal parity law does not require health insurance plans to cover MH & SUD benefits; it only imposes requirements on plans that do choose to provide such benefits. However, the Affordable Care Act (ACA) includes MH & SUD benefits in its list of Essential Health Benefits, meaning certain types of plans—namely plans sold to individuals & small groups on the marketplace and Medicaid plans for the “expansion population” under the ACA—must cover those benefits and cover them at parity

Therefore, some plans must provide MH & SUD benefits to comply with the ACA, and they must provide the MH & SUD benefits equally with medical & surgical benefits because of the federal parity law.

Summary: Who Must Comply?
Parity Guide, p. 12 If offer MH/SUD, must comply with parity Must offer MH/SUD, and comply with parity Not required to comply with parity** Large group plans Medicaid Managed Care plans Grandfathered individual plans offered outside marketplace/exchange State & local government plans* Church-sponsored plans* Federal govt. plans *May opt out Individual & small group plans sold on marketplace Non-grandfathered small group & individual plans offered outside marketplace Medicaid ABPs Medicare Traditional (fee-for-service) Medicaid Grandfathered small group plans offered outside marketplace Plans w/cost increase exemption Retiree-only Tri-Care **Note: these plans may be required to comply with state parity or other laws

What Is the Federal Parity Law? 3. What Does It Require?
Parity Guide, p. 13

Federal Parity Law: What Does It Require?
Remember what federal parity law does not require: Federal parity law does not require plans to cover SUD or MH benefits But, Affordable Care Act does require some plans to cover SUD & MH benefits, and NYS law also requires most NY plans to cover SUD & MH benefits What parity law does require: For plans that do cover MH/SUD benefits, parity law requires they be covered comparably to other medical/surgical benefits

Parity Guide, p. 8 The federal parity law requires that financial requirements and treatment limitations be no more restrictive for MH/SUD benefits than for medical/surgical benefits.

Parity Guide, p. 13 What are financial requirements and treatment limitations?

Parity Guide, p. 13 What are financial requirements? Deductibles Co-payments Co-insurance Out-of-pocket maximums

Parity Guide, p. 13 What are treatment limitations? There are 2 kinds of treatment limitations: Quantitative Treatment Limitations Non-Quantitative Treatment Limitations (NQTLs) Cont.….

Parity Guide, p. 13 What are treatment limitations? Quantitative treatment limitations are those expressed numerically, such as Limits on the number of days or visits covered Limits on the frequency of treatment Cont.….

Parity Guide, p. 17 What are treatment limitations, cont… Non-Quantitative treatment limitations (NQTL) are not expressed numerically, but otherwise limit scope/duration: Medical necessity criteria Preauthorization requirements Prescription drug formulary design Fail-first or step therapy policies Cont.….

Parity Guide, p. 13 What are treatment limitations, cont… Non-Quantitative treatment limitations (NQTL), cont.… Standards for provider admission to participate in-network Determination of usual, customary, reasonable amounts Exclusions based on failure to complete a course of treatment Geographic limitations *Note: this is not an exhaustive list

CASE STUDY: Question Jay visits a psychologist once per week. His health insurance plan requires a $50 co-payment each time he visits his psychologist. Is this co-payment a financial requirement or treatment limitation that is covered by the federal parity law?

CASE STUDY: Possible Answers
Yes, it is a financial requirement. Yes, it is a treatment limitation. No, it is not a financial requirement or treatment limitation.

CASE STUDY: Correct Answer
Yes, it is a financial requirement. Co-payments (like the $50 Jay must pay each time he sees his psychologist) are financial requirements, and therefore they must comply with the federal parity law.

Now you know what financial requirements and treatment limitations are… so what does the parity law say about them specifically?

Parity Guide, p. 9 First, plans may not have separate financial requirements or treatment limitations that apply only to MH/SUD benefits.

CASE STUDY: Question Claire’s health plan imposes a $500 deductible on MH/SUD benefits. The plan does not impose a deductible on medical/surgical benefits. Does this violate the federal parity law?

Yes, it violates the law. No, it does not violate the law.

Yes, this violates the federal parity law. Claire’s plan has a separate financial requirement— the deductible—that applies only to MH/SUD benefits and not to medical surgical benefits. This is not allowed under the federal parity law.

Parity Guide, p. 9 Second, plans must provide out-of-network benefits for MH/SUD services if they provide them for medical/surgical benefits.

CASE STUDY: Question Manny’s health plan allows him to visit both in-network and out-of-network providers for medical/surgical needs (for example, an in-network or out-of-network neurologist). However, his plan only allows him to visit in-network health care providers for MH/SUD treatment (for example, only in-network psychiatrists). Does Manny’s plan comply with the federal parity law?

Yes, it complies. No, it does not comply.

B. No, this likely does not comply with the federal parity law.* The law says if a plan provides out-of-network benefits for medical/surgical services (like the neurologist), it must provide out-of-network benefits for MH/SUD services (like the psychiatrist). Manny’s plan is not following this requirement of the law. *It “likely” does not comply, because more information is needed to say for sure.

Parity Guide, p. 8 Third, plans may not apply financial requirements or treatment limitations to MH or SUD benefits that are more restrictive than the predominant financial requirements and treatment limitations applied to substantially all medical/surgical benefits.

What does all that mean? We are going to talk a lot about this one.

CASE STUDY: Question Hayley’s health plan only allows 30 psychologist visits per year. There is no similar visit limit on the medical/surgical side (for example, she can visit her primary care doctor as often as she wants). Does Hayley’s plan comply with the federal parity law?

Yes, it complies. No, it does not comply.

B. No, this likely* does not comply with the federal parity law. Hayley’s plan is placing a treatment limitation (visit limits) on MH/SUD benefits (psychology services) that it is not placing on medical/surgical benefits (primary physician when sick). Therefore, the plan is applying a treatment limitation to MH/SUD that is likely more restrictive than what it’s applying to medical/surgical. *It “likely” does not comply, because more information is needed to say for sure. This will be discussed in more detail later.

What Is the Federal Parity Law? 4. The Details

Federal Parity Law: The Details
Remember, the federal parity law says plans: may not apply financial requirements or treatment limitations to MH or SUD benefits that are more restrictive than the predominant financial requirements and treatment limitations applied to substantially all medical or surgical benefits. What does that mean?

Parity Guide, p. 13 How do you know if financial requirements & treatment limitations are more restrictive for MH/SUD benefits than for other medical/surgical benefits?

Parity Guide, p. 14 The federal parity law’s regulations require all of a plan’s MH/SUD benefits and all of its medical/surgical benefits to be placed in one of 4 classifications (Medicaid & CHIP) or 6 classifications (private insurance). MH/SUD benefits are compared to medical/surgical benefits within the same classification.

Parity Guide, p. 14 4 classifications (Medicaid & CHIP): Inpatient Outpatient Emergency care Prescription drugs

Parity Guide, p. 14 6 classifications (private insurance): Inpatient, in-network Inpatient, out-of-network Outpatient, in-network Outpatient, out-of-network Emergency care Prescription drugs

Parity Guide, p. 14 6 Classifications, cont.… Compare MH/SUD benefits in a classification with other medical/surgical benefits in that same classification… Are the financial requirements & treatment limitations on the MH/SUD benefits are more restrictive? E.g., compare inpatient MH/SUD with inpatient medical/surgical In other words, compare like with like.

CASE STUDY: Question Jay is wondering whether the $50 co-payment he is required to pay at his weekly visit to his psychologist complies with the parity law—that is, whether this financial requirement for an MH/SUD benefit is equal to similar medical/surgical benefits. Should Jay check to see whether the $50 co-payment for his psychologist visits is equal to: The co-payment he makes when he visits his primary care physician when he’s sick, or The co-payment he makes for a visit to the emergency room?

The co-payment he makes when he visits his primary care physician when he’s sick The co-payment he makes for a visit to the emergency room

The co-payment he makes when he visits his primary care physician when he’s sick First: How does Jay’s plan classify his psychologist visits? Most likely: “outpatient” category. Second: Compare Jay’s co-payment for the psychologist—an outpatient visit—to his co-payment for outpatient visits on the medical/surgical side, such as visits to a primary care physician when he is sick. Don’t: Compare Jay’s co-payment for an outpatient visit to his co- payment for an emergency service or inpatient visit

CASE STUDY: Correct Answer, cont.
Remember: Compare like with like! MH/SUD Medical/Surgical Inpatient Detoxification Appendicitis Outpatient Psychologist visit Primary care visit when sick Emergency Care ER for overdose ER for broken leg Prescription Drugs Suboxone Blood pressure medication

Parity Guide, p. 15 6 Classifications, cont.… If a health plan offers MH/SUD benefits in any classification, MH/SUD benefits must be provided in every classification in which medical/surgical benefits are provided.

CASE STUDY: Question Gloria’s health insurance plan covers both outpatient and inpatient treatment for medical/surgical ailments. For example, it covers outpatient visits to her primary care doctor when she gets sick, and inpatient stays at the hospital when she has appendicitis. Her plan also covers outpatient MH/SUD treatment—for example, outpatient addiction counseling. However, her plan will not cover inpatient detoxification for her addiction. Does Gloria’s plan meet the requirements of the federal parity law?

Yes, it meets the requirements of the law. No, it does not meet the requirements of the law.

B. No, it probably* does not meet the requirements of the federal parity law (meaning it is probably illegal). Because Gloria’s health plan offers MH/SUD benefits in any classification (in this case, it offers them in the outpatient classification), it must offer them in every classification in which it offers medical/surgical benefits (in this case, both outpatient and inpatient). *It “probably” does not comply, because more information is needed to say for sure.

Once all of the benefits have been put into one of the 6 classifications, how do you compare financial requirements & treatment limitations for MH/SUD vs. medical/surgical to figure out if they are more restrictive for MH/SUD?

Parity Guide, p. 13 For financial requirements and quantitative treatment limitations: cannot impose any on MH/SUD benefits that are separate from or more restrictive than the predominant ones applied to substantially all medical/surgical benefits in the same classification

What does all that mean?

Parity Guide, p. 16 What do I need to know about “predominant” and “substantially all”? They are part of a mathematical formula created by the law for comparing MH/SUD benefits with medical/surgical benefits. You don’t need to get bogged down in the details of the formula. If you see something that looks like a violation of the parity law, you can report it to the appropriate entity and they will do the analysis using the formula. We’ll talk more about that later.

Parity Guide, p. 17 For non-quantitative treatment limitations (NQTLs): cannot impose any NQTLs on MH/SUD that are not comparable to those used for medical/surgical, and cannot apply them more stringently to MH/SUD than medical/surgical

CASE STUDY: Question Mitchell’s health plan requires him to get prior authorization that a treatment is medically necessary for all inpatient medical/surgical benefits and all inpatient MH/SUD benefits. In practice, his plan routinely approves seven days of inpatient benefits for medical/surgical conditions , after which the patient's attending provider must submit a treatment plan for approval. On the other hand, Mitchell’s health plan routinely approves only one day of inpatient MH/SUD benefits, after which his attending provider must submit a treatment plan for approval. Does Mitchell’s plan violate the federal parity law?

Yes, it violates the law. Mitchell’s plan is applying a stricter non-quantitative treatment limitation in practice to MH/SUD benefits than is applied to medical/surgical benefits. Even if a NQTL is equal on paper, if it is applied more stringently in practice it can still violate the law.

CASE STUDY: Question Cameron’s health plan applies concurrent review to types of inpatient care where the length of stay tends to vary greatly. The plan uses a mathematical formula to determine which types of inpatient care have a lot of variation. In practice, after applying the formula, the plan applies concurrent review to 60% of MH/SUD conditions, but only 30% of medical/surgical conditions, because the formula found more variation in MH/SUD inpatient stays than in medical/surgical. Does Cameron’s plan violate the federal parity law?

B. No, it does not violate the law. Cameron’s plan is applying the same evidentiary standard to MH/SUD and medical/surgical benefits to determine when to do concurrent review (evidentiary standard here is mathematical formula to determine which inpatient stays have most variation in length) So, even though the standard results in an overall difference in the application of concurrent review for MH/SUD and for medical/surgical conditions, it does not violate parity law, because standard not applied more stringently to MH/SUD than medical/surgical

CASE STUDY: Question Luke’s health plan automatically excludes coverage for inpatient SUD treatment in any setting outside of a hospital (such as a freestanding or residential treatment center). For inpatient treatment outside of a hospital for other conditions (including freestanding or residential treatment centers prescribed for mental health conditions, as well as for medical/surgical conditions), the plan will provide coverage if the prescribing physician obtains authorization from the plan that the inpatient treatment is medically appropriate for the individual, based on clinically appropriate standards of care. Does Luke’s plan violate the federal parity law?

Yes, it violates the law. Although the same non-quantitative treatment limitation— medical appropriateness—is applied to both MH/SUD benefits and medical/surgical benefits, the plan's unconditional exclusion of SUD treatment in any setting outside of a hospital is not comparable to the conditional exclusion of inpatient treatment outside of a hospital for other conditions.

Parity Guide, p. 24 This stuff is confusing…if the details get overwhelming, just look for the RED FLAGS!

Red Flags: Having 1 deductible for MH/SUD services and 1 for medical/surgical services that accumulate separately Limits on the # of days or visits for MH/SUD treatment, when there aren’t similar limits for medical/surgical Higher co-payments & co-insurance for MH/SUD than for medical/surgical (e.g., charging a “specialist” rate for MH/SUD outpatient visits, when a “specialist” rate isn’t charged for most medical/surgical outpatient visits) Cont.….

Red Flags, cont.…. Requiring patient to “fail first” at MH/SUD outpatient treatment before approving residential or inpatient treatment (and not having similar policies for med/surgical) Requiring MH/SUD patients to get prior authorization at earlier stages of treatment or more frequently during treatment than medical/surgical patients Cont….

Red Flags, cont.… Excluding intermediate levels of MH/SUD care, like residential treatment, from coverage, if the plan covers intermediate care (like skilled nursing) for medical/surgical Requiring MH/SUD patients to be treated in-state, but allowing medical/surgical patients to be treated out-of-state Cont….

Red Flags, cont.… Putting yearly or lifetime limit on length of time patient can receive methadone, buprenorphine, or naltrexone—or not covering those medications at all Refusing to cover MH/SUD treatment because patient failed to complete previous treatment or because “the patient is not improving” Refusal to provide information, like medical necessity criteria, when you request it (more on this coming up!)

If you see a red flag and don’t want to get bogged down in the complexities of the federal parity law, just report it! Next up: What to do if you see a red flag or think a plan may be violating the federal parity law…..

ANY QUESTIONS?

How Can Patients & Providers Enforce Their Rights under the Federal Parity Law?
Transparency Requirements Appeals Government Enforcement Lawsuit Parity Guide, p. 31

Federal Parity Law: Enforcing Rights
Steps to Take: Request information from health insurance plan. File internal appeal; if denied, file external appeal. If appeal(s) denied, contact government agencies that enforce the law. Additional option: Lawsuit. Note: You are not necessarily required to file appeals before contacting government agencies, but they will likely tell you to do so when you contact them before they will get involved.

How To Enforce Rights? 1. Transparency Requirements
Parity Guide, p. 23

Enforcing Federal Parity Law: First, Request Information
Transparency Requirements: Providers & patients have the right to certain information from health plans under the federal parity law (& other laws)…. Cont.….

Enforcing Federal Parity Law: First, Request Information
Parity Guide, p. 23 Transparency Requirements, cont.…. Most plans must provide, if you request it: Criteria used to make medical necessity decisions—both MH/SUD and medical/surgical Written explanation of how non-quantitative treatment limitations (e.g., medical necessity criteria) are applied to their medical/surgical & MH/SUD benefits; Reason for denials of payment or reimbursement; Any additional evidence used to make benefit determinations during appeals. SAMPLE REQUEST – “Parity Guide” p. 88 Generally must be provided within 30 days and free of charge

How To Enforce Rights? 2. Appeals

Enforcing Federal Parity Law: Second, File Appeals
Parity Guide, p. 31 Internal & External Appeals: Ask the health plan how to file appeals. Look into expedited appeals if need be. Internal appeals: conducted by the health plan External appeals: conducted by 3rd party reviewers (not the plan). In NYS most external appeals are conducted by the State Dept. of Financial Services. For both internal & external appeals: Pay careful attention to deadlines! Cont.….

Enforcing Federal Parity Law: Second, File Appeals
Parity Guide, p. 75 – sample appeals Internal & External Appeals, cont.…. Community Health Advocates can help with appeals: Tip: Be sure to specifically mention state and federal parity laws in your appeals—otherwise, those laws may not be considered, and courts may not be able to consider them later on if you want them review the outcome of your appeals.

How To Enforce Rights? 3. Government Agencies

Enforcing Federal Parity Law: Third, Contact Govt. Agencies
If you think a health plan is violating the federal parity law, you can complain to the government agencies that are tasked with enforcing the law, and you can complain to the State Attorney General. Cont.….

New York State Attorney General: NYS AG is proactively enforcing the federal parity law If you think a NYS health plan is violating parity, you can call the AG’s Health Care Bureau hotline or fill out online complaint form: Cont.….

NYS Attorney General, cont.….. AG has settled 6 cases against NYS health plans for parity violations so far (Cigna, MVP Health Care, Emblem Health, ValueOptions/BeaconHealthOptions, Excellus, & Healthnow) AG has also reached settlements under which 2 health plans have agreed to stop requiring prior authorization for medication- assisted treatment for SUD (Cigna & Anthem) Cont.….

NYS Attorney General, cont.….. Settlements have required various insurers to… End prior authorization for MAT (Anthem/Empire, Cigna) Conduct outreach & education about MAT & include more MAT providers in-network (Anthem/Empire) Cover residential BH treatment Cover partial hospitalization & intensive outpatient Cover outpatient SUD tx in office setting, including MAT Cont.….

NYS Attorney General, cont.….. Apply primary care co-payment amount to outpatient BH services Remove day and/or visit limits for outpatient BH services End practice of approving only 1 day or 1 visit for BH services End prior authorization & concurrent review for outpatient BH services End fail first policies Ensure accuracy of provider network & online provider directory Cont.….

NYS Attorney General, cont.….. Reimburse for out-of-network services at usual & customary rate Change utilization review tool and/or process Stop imposing heightened utilization review on beneficiaries who have utilized more than a specified amount of BH services (e.g., Outpatient Outlier Model) Change SUD medical necessity criteria Post medical necessity criteria on website Provide better explanations in denial letters Cont.….

NYS Attorney General, cont.….. For information about what the AG said violated the parity law, what remedies & penalties AG has imposed on which insurers, and copies of the AG’s settlement agreements, visit: care-access-resources/new-york-attorney-general-parity- enforcement/

New York State Attorney General, cont.… The AG can also enforce other federal laws (like the ACA) and state laws (like the state parity law).

Parity Guide, p. 47 Other Govt. Enforcement Options: The AG is just one option for enforcing the parity law The federal parity law itself gives enforcement authority to a variety of state and federal agencies Different agencies enforce federal parity law for different types of health plans Remember, it is advisable to appeal directly to the insurance plan before going to a government agency Cont.….

How to Enforce Parity Rights
Complain to Government Agencies, cont… State Agencies Unless plan is self-insured, complain to state agencies first Dept. of Fin. Svcs. Dept. of Health Online complaint form: Consumer Assistance Unit: (800) Phone: (800) or (800)

Complain to Government Agencies, cont… State Agencies Dept. of Fin. Svcs. Dept. of Health Plan Types: Fully-insured large group Small group bought on marketplace Non-grandfathered small group not bought on marketplace Individual Fully-insured state or local govt. employer Medicaid Managed Care CHIP

Complain to Government Agencies, cont… Federal Agencies If state agencies are not “substantially enforcing” the federal parity law, or if a plan is self-insured, complain to federal agencies Dept. of Health & Human Svcs. Dept. of Labor Phone: (877) ext Online: Phone: (866)

Complain to Government Agencies, cont… Federal Agencies Dept. of Labor Dept. of Health & Human Svcs. Plans: Self-insured large group plans (both grandfathered & non-grandfathered) Self-insured state or local govt. plans Fully-insured large group Small group bought on marketplace Non-grandfathered small group not bought on marketplace Individual Fully-insured state or local govt. employer Medicaid Managed Care CHIP

That’s a lot of information! Don’t worry too much about which government agency has enforcement authority over which type of plan Government agencies have said they will help patients’ & providers’ complaints get to the appropriate agency.

Parity Guide, p. 75 A few tips for complaining to govt. agencies: Mention the federal parity law specifically in your complaint—otherwise the agency may not look for parity violations Ask the government agency to provide you with its findings/conclusions in writing SAMPLE COMPLAINTS in the “Parity Guide” – p. 75

How To Enforce Rights? 4. Lawsuits

Enforcing Federal Parity Law: Additional Option—Lawsuit
Depending on type of health plan, may be able to enforce rights under the federal parity law by filing a lawsuit in court against the insurance company To pursue this option, you and/or your patient should speak to an attorney

ANY QUESTIONS?

Relevant New York State laws
Additional info in handouts Parity Guide, p. 29

Court-Ordered Treatment—Insurance Coverage:
Other Laws to Know Court-Ordered Treatment—Insurance Coverage: NY law requires Medicaid Managed Care plans in the state to cover court-ordered treatment (if the plan would otherwise cover that type of treatment) Example: Court orders defendant charged with sale of controlled substances into outpatient addiction treatment. If the person’s Medicaid plan provides coverage for outpatient addiction treatment generally, it would be required to cover that type of treatment when ordered by a court. This law is found at New York Social Services Law section 364-j(4)(r)

Required Coverage of Mental Health Care:
Other Laws to Know Required Coverage of Mental Health Care: NY law requires most health insurers to cover: At least 30 days of inpatient MH care At least 20 days outpatient of MH care NY law requires most health insurers to reimburse for MH services regardless of whether they are provided by physician, psychiatrist, psychologist, or licensed clinical social worker

NY Laws Responding to Opioid Crisis
Other Laws to Know NY Laws Responding to Opioid Crisis (passed in 2014 & 2016) Most plans must cover inpatient & outpatient SUD services, including detox & unlimited medically necessary residential treatment Most plans must cover up to 20 outpatient visits per year for family members of people with SUD Most plans, when conducting utilization review for SUD benefits, must use evidence-based & peer reviewed tools designed by OASAS and appropriate to age of patient (LOCADTR) Cont.….

NY Laws Responding to Opioid Crisis, cont…
Other Laws to Know NY Laws Responding to Opioid Crisis, cont… Most plans must cover all FDA-approved medications for detox or maintenance treatment of SUD Most plans must cover immediate access, without prior authorization, to 5-day emergency supply of SUD medications Forbid Medicaid plans from requiring prior authorization for prescription of buprenorphine or Vivitrol for detox or maintenance treatment of SUD Cont.….

NY Laws Responding to Opioid Crisis, cont…
Other Laws to Know NY Laws Responding to Opioid Crisis, cont… Most plans cannot require preauthorization for inpatient SUD treatment or conduct concurrent review for the first 14 days of inpatient SUD treatment… Provided the inpatient facility is in the plan’s network and the facility notifies the insurer of the admission and the initial treatment plan within 48 hours of admission After the first 14 days of inpatient treatment, the plan can review the treatment and can only deny under certain circumstances – if the plan denies coverage for first 14 days, patient is not responsible for paying (other than co-payment, etc.) Cont.….

Naloxone (Narcan) in NY
Other Laws to Know Naloxone (Narcan) in NY Now available at many pharmacies without prescription, including: CVS, Rite Aid, Walgreens, and more Directory available from Dept. of Health: ose_prevention/directories.htm

ANY QUESTIONS? Reminder: You can call legal action center with questions at 212-243-1313

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The Federal Parity Law March 21, 2017

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