HHS Parity Session Reveals Concerns Over Treatment Barriers, Reimbursement
Mental Health Weekly July 31, 2017
HHS officials said they will continue to allow comments on parity through Aug. 10.
The U.S. Department of Health and Human Services (HHS) on July 27 hosted a Public Stakeholder Listening Session on Strategies for Improving Parity for Mental Health and Substance Use Disorder Coverage. The listening session on improving parity was mandated in the 21st Century Cures Act.
Officials from the HHS, the Department of Labor, the Treasury Department and the Centers for Medicare & Medicaid Services served as panelists. Agency officials noted that following the listening session and upon receiving further comments related to the Mental Health Parity and Addiction Equity Act (MHPAEA), they will put together an action plan.
Stakeholders providing testimony included the National Alliance on Mental Illness (NAMI), the National Association of Psychiatric Health Systems (NAPHS), the Association of Behavioral Health and Wellness (ABHW), Blue Cross Blue Shield, the American Psychiatric Association and several other stakeholders.
Testimonies from stakeholders ranged from the need for provider reimbursement and enforcement to further clarification on the parity law. One of the speakers commented that a focus on clarification should be for the benefit of patients and that mental health parity rules should be simplified.
Mark Covall, president and CEOof NAPHS, told the panelists that even though parity is working, the pace is slower for people needing proper care. “Our goal is to ensure that every American with behavioral health conditions receives the right treatment,” Covall said.
The Medicaid and Medicare policies disproportionately affect the poorest Americans and those with the severest behavioral health conditions. “They cannot receive lifesaving treatment,” Covall said. The mental health parity regulations include examples of parity violations related to the nonquantitative treatment limitations (NQTLs), he said.
Medicare has a benefit limitation of 190 days of inpatient psychiatric care in a person’s lifetime, he said. “No other service has this kind of arbitrary cap,” he said. Covall urged HHS to eliminate such discriminating policies.
Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness, noted that federal regulators have been helping in working with ABHW member companies and the states HHS from page 1 when states have had an incorrect interpretation of federal guidance. “We appreciate their assistance and have several recommendations on how to improve the federal/state enforcement of MHPAEA,” she said. The recommendations included:
1. Educate states to create consistent understanding and implementation of the law.
2. Simplify the disclosure requirements.
3. Change the overly restrictive NQTL requirements.
4. Share deidentified information.
In reference to NQTLs, Greenberg noted that parity in NQTLs was not something envisioned by the legislators when they passed the MHPAEA; however, they are included in the regulations. The parity analysis has become a strict one-way analysis with no recognition of the differences that do exist between behavioral health and physical health.
The language included in the interim final rule that allowed clinical guidelines to permit a difference when performing the NQTL analysis should be restored, she said.
“More uniformity in the interpretation and enforcement of MHPAEA in both the commercial and public sectors would make a world of difference to payers implementing the law,” she said.
Carrie Dorn from the National Association of Social Workers testified that evidence-based, comprehensive mental health and substance use disorder services must be accessible. Parity provisions must be clarified and strengthened, she said. “We encourage HHS to eliminate barriers to behavioral health interventions and services for SUD treatment,” she said.
Dorn noted the need for improvement of transparency of mental health standards to provide consistency on how parity is implemented among insurance companies. She added that HHS should encourage insurance companies to report on in-network provider capacity in relation to the needs of consumers in their network and to determine if insurers are meeting the demands at a local level. “Improving coverage for and access to behavioral health services will help strengthen communities,” she said.
ABHW seeking parity accreditation
The ABHW expressed interest in an accreditation for parity soon after the parity regulations were released, Greenberg told MHW. “We recognized that the rules were difficult to interpret and complex to implement and believed that an accreditation would help identify whether or not plans were approaching parity compliance in the right manner,” she said.
Greenberg added, “We have been speaking with employees of the Clear Health Quality Institute for about 18 months about developing an accreditation for parity, and at the end of last year a diverse group of stakeholders, including ABHW, began meeting to discuss the concept.”
The challenge will be seeing whether or not this group can come to agreement on the most appropriate standards for such an accreditation, Greenberg said. “Our belief is that an accreditation will be useful to state and federal governments, consumers, providers and others in knowing whether or not a plan is approaching parity in the correct manner. A parity accreditation will hopefully bring some desperately needed uniformity to MHPAEA implementation.”
A personal look
Sita Diehl, director of policy and state outreach for NAMI, spoke about her 27-year-old son who lives with autism, major depressive disorder and attention deficit disorder. Because her husband is a federal employee, they have enjoyed parity coverage in the Federal Employee Health Plan since the mid-1990s, she said. “Our story demonstrates the potential of parity if fully implemented,” she said.
Diehl said her son is now transferring to the Massachusetts Institute of Technology, where he will pursue a doctorate in chemistry. “He knows himself very well and manages his care with the help of a psychiatric nurse practitioner,” she said. Parity mental health coverage has provided him with the treatment he needs to reach his full potential, Diehl said.
Diehl also commented on the need for parity in provider rates. “To address the mental health workforce shortage, policies should be put in place that enable providers to make a livable wage,” she said.
“We can do far better by assertively enforcing federal parity law,” said Diehl. She said the following is what is needed:
Federal and state regulators should require periodic reports from insurers to demonstrate parity compliance, and should follow up assertively when discrepancies emerge. Regulators should monitor health plans to ensure parity in provider rates and application of administrative procedures. Early identification and intervention should be strengthened by requiring mental health screening and assessment as a benefit in all public and private insurance plans. Consumers should be educated on their rights under parity law, complaint procedures and the assistance available to file complaints.
“The listening session was laudable,”Diehl told MHW in an interview following the session. “There is a lot of confusion regarding the federal parity law. Enforcement shouldn’t rest on consumer complaints the way it does now.”
Diehl noted that there should be regular reporting requirements from health plans to regulators. Regulators should follow up when there are discrepancies and submit evidence on that, she said.
Diehl added, “ We need an education process to understand NQTLs and the MHPAEA and how to enforce it.” Consumers say they need transparency, said Diehl. “They need to see what their parity rights are and how to file complaints if their parity rights are in question or have not been honored,” she said. “Consumers should be able to see which plans have had some trouble with parity.” They should be informed when they’re purchasing a plan that the plan is in compliance with parity, she said.
“I believe, although it wasn’t said explicitly, that HHS will consider the testimony as they attempt to forge strategies to enforce MHPAEA and other federal parity law,” said Diehl.