State policymakers have a critical role to play in how the Mental Health Parity and Addictions Equity Act (MHPAEA) is operationalized in state programs, including Medicaid managed care organizations, alternative benefit plans, and the Children’s Health Insurance Program (CHIP). Now that CMS has released long-awaited proposed rules on implementation of the MHPAEA in these programs, policymakers have an opportunity to comment on the rule and start thinking about how to implement its provisions going forward. The proposed rule is open for comment until June 9th, 2015 and can be accessed here.
The MHPAEA does not require that health insurers or health plans cover mental health or substance use disorder services (MH/SUD). Very generally, the act does require the following:
- Health insurers and health plans that provide these services must provide the benefits at the same level as medical/surgical benefits.
- If included as a benefit, health insurers and health plans may not impose more restrictive financial requirements, additional cost-sharing, different treatment limitations, or different out-of-network requirements for these services than for medical/surgical benefits.
- Medical necessity criteria used to deny these services must be available upon request.
The Affordable Care Act further requires that state alternative benefit plans include MH/SUD services as part of their essential health benefits, and mandates that those benefits be offered at parity with medical/surgical services.
Prepare for the parity analysis. Are your Medicaid MH/SUD services carved in or carved out? The rule proposes that if a state provides any Medicaid state plan benefits to enrollees under an MCO contract, those enrollees receive the protections of the MHPAEA. States that cover their medical/surgical benefits through a managed care organization, and carve out MH/SUD services through other arrangements (such as through a Behavioral Health Organization, or fee-for-service) will need to provide evidence of compliance with parity. States that have multiple MCO and BHO contracts will want to review their various vendor combinations to make sure that Medicaid enrollees have access, regardless of how their MH/SUD services are arranged.
Define your terms. Whether states have their MH/SUD services carved in or carved out, the analysis of parity may still be tricky. While quantitative limitations (Number of visits, for example) may be a more straightforward comparison, “nonquantitative treatment limitations” – such as prior authorizations, continuing review, and stepped therapy – can be harder to compare, and has some states thinking about standardizing terms in order to simplify the analysis. State policy makers will also want to pay close attention to so-called “intermediate services” – more specialized MH/SUD services for which there are no easy comparisons in the medical/surgical world (think substance use residential treatment, for instance).
Plan ahead for any additional costs. Section 438.6(e) of the proposed rule would allow state Medicaid agencies to include benefits beyond the state plan in the MCO capitation rate, to the extent that those benefits are necessary to comply with the parity rules. Policymakers will want to plan ahead to ensure that any increases required in capitation rates are part of state Medicaid budgeting. Note that CMS is interested in receiving comments on this provision, and how to mitigate the risk that could come with overbroad state interpretations.
Be aware of unique challenges. Federal rules prohibit Medicaid federal financial participation for treatment at so-called Institutes of Medical Disease (IMDs) for Medicaid enrollees between the ages of 18 and 65. Other services, like Methadone or Buprenorphine assisted treatment, can be heavily regulated at both the state and federal level regarding how, where, and by whom these treatments are delivered – which can result in limited access. Policymakers will want to track how these limitations impact their Medicaid parity analysis.
Coordinate benefits. Low-income adults and children with serious MH/SUD issues may move through various health coverage options (Medicaid, CHIP, ABPs) as income and health status change. Differences across these benefit packages will persist due to varied medical necessity criteria, service definitions, and service limitations. As implementation of parity regulation moves forward, state policymakers will want to pay particular attention to how individuals with serious mental health needs move between benefit plans in order to ensure coordinated care and continuity with treatment providers, medication, and community supports.
Keep working on workforce. A 2013 report to Congress from the Substance Abuse and Mental Health Services Administration highlighted the significant challenges facing the aging and under-funded MH/SUD work force. Expansion of health care coverage through the Affordable Care Act is expected to increase the demand for these services. Parity is therefore only a piece of the puzzle for state policy makers looking to ensure network adequacy and access to services. States are already tackling the work force shortage through varied approaches such as telehealth, psychiatrist extenders, education loan forgiveness programs, and the use of grant funding to encourage the growth of MH/SUD services in underserved areas. States are also looking to integrated physical/mental health care initiatives and safety net providers, such as Federally Qualified Health Centers, to help with the expected increase in demand.
According to the proposed rule, states will have up to 18 months after the final regulation is posted to comply with parity requirements. Additional information about the MHPAEA proposed rule and its impact on state Medicaid programs can be found at the CMS MHPAEA webpage.