2021 Mental Health Parity (MHP) AnalysisPre-Analysis Webinar

Melissa Isavoran, MS – Associate Executive Director, HSAGAmy Lewis, BSN, RN, CPHM – Director, HSAG

Barbara McConnell, MBA, OTR – Executive Director, HSAG

April 19, 2021

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Agenda

• MHP Background and Authority

• Oregon’s 2020 MHP Analysis Summary and Results

• 2021 MHP Analysis Overview and Process (Protocol)

• Documentation Submission

• Pending Legislation (HB3046)

• Questions and Answers

Objectives:

• To provide a summary of MHP requirements.

• To provide an overview of 2021 MHP Analysis activities.

• To discuss CCO and OHA responsibilities and expectations.

• To highlight current legislation that may impact future MHP analyses.

• To ensure a forum for questions and answers.

MHP Background and Authority

MHP Regulations

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MHP Act 1996 MHP and Addiction Equity

Act (MHPAEA) 2008

Children's Health Insurance Program (CHIP) Reauthorization

Act 2019

Affordable Care Act (ACA)

2010

42 CFR §438 Subpart K

March 30,2016

Prohibits lifetime/annual dollar limits for MH if aggregate limits not also

applied to medical

Full parity for financial

requirements and treatment

limitations; added substance

use disorder

Applies provisions of

MHPAEA to the CHIP Program

Applies parts of MHPAEA to Medicaid

Alternative Benefit Plans

Applies parity to Medicaid

managed care

Compliance by October 2, 2017

The intent of MHP is to prevent inequity between the application of mental health (MH)/substance use disorder (SUD) and medical surgical (M/S) benefits to promote greater consistency for beneficiaries.

Key MHP Requirements

Medicaid managed care regulations (42 CFR §438, Subpart K)

• Prohibits more restrictive limits and requirements to mental health/substance use disorder (MH/SUD) benefits than those applied to medical/surgical (M/S) benefits.

• Prohibits annual lifetime or annual dollar limits (AL/ADLs) to MH/SUD benefits unless dollar limits apply to at least one-third of M/S benefits.

• Prohibits the application of financial requirements (FR) and quantitative treatment limitation (QTL) to MH/SUD benefits more restrictive than those applied to M/S.

• Prohibits non-quantitative treatment limits (NQTL) to MH/SUD benefits unless the NQTL is comparable to and applied no more stringently than those used in M/S benefits in the same classification.

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Key MHP Requirements, Continued…

• MH/SUD and M/S benefits must be defined consistent with a “generally recognized independent standard of medical practice,” and for comparability, must be mapped to each of four classifications:

• Parity does not mandate coverage of MH/SUD benefits, but when coverage for MH/SUD benefits is provided, coverage must be provided in every classification in which M/S benefits are provided.

• Criteria for medical necessity determinations for MH/SUD benefits must be made available to beneficiaries and providers upon request, as well as the reason for denial of reimbursement or payment for MH/SUD benefits.

• States must implement monitoring procedures to ensure continued compliance and to identify when changes in benefit design or operations could affect compliance and require an updated analysis.

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Emergency CarePrescription Drugs OutpatientInpatient

Limits Defined

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FRs QTLs AL/ADLs NQTLs

Beneficiary cost-sharing (e.g., copayments, coinsurance, and deductibles) in addition to payments made by the state, MCO, PIHP, or PAHP for services.

Limits on the scope or duration of a benefit that are expressed numerically. This includes day or visit limits.

Dollar limits on the total amount of a specified benefit over a lifetime or on an annual basis.

Limits on the scope or duration of benefits, such as prior authorization or network admission standards.

MHP regulations require the performance of analysis of limits on MH/SUD benefits to determine if they are compliant with parity.

Comparability and Stringency

MHP regulations address comparability and stringency of NQTLs applied to MH/SUD benefits in writing and in operation.

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Oregon MHP Requirements

To ensure monitoring of MHP, the CCO 2.0 Health Care Services Contract, Exhibit M requires that CCOs annually report on and provide documentation demonstrating compliance with 42 CFR, Subpart K to confirm that any limitations (such as prior authorization requirements and general provider availability) imposed on accessing MH/SUD services are not substantially different from, or more limiting than, those for M/S benefits.

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OHA worked with HSAG to standardize and prioritize annual reporting:• 2020 – Full reporting and MHP analysis.• 2021 – MHP Attestation and adverse benefit determination (ABD)

record review.• All Years – Material change reporting based on significant change to

contracts, operations, and/or delegation agreements (under development).

Oregon’s 2020 MHP AnalysisSummary and Results

Oregon’s 2020 MHP Analysis

In 2020, CCOs participated in a MHP Analysis of the Oregon Health Plan’s (OHP’s) full delivery system. The analysis: • Included an inventory of all MH/SUD and M/S benefits offered to OHP

members and the limitations applied to those benefits.

• Determined whether each CCO’s MH/SUD and M/S NQTLs were applied using comparable methods and similar levels of evidence in support of applying the limit and specific rationales and evidence for how stringently the limit was applied.

• Assessed Each CCO’s NQTLs against OHP fee-for-service (FFS) MH/SUD and M/S in classifications of NQTLs.

• Did not include analysis of AL/ADLs, FRs, or QTLs.

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Note: The 2020 MHP Analysis was based on guidance from Centers for Medicare & Medicaid Services (CMS): Parity

Compliance Toolkit Applying Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children’s

Health Insurance Programs: https://www.medicaid.gov/medicaid/benefits/behavioral-health-services/parity/index.html

Oregon Mapping Guide

OHA revised the Oregon Mapping Guide as an inventory that defined how CCOs and OHA assigns services to MH/SUD and M/S Groupings and are based on:

• Essential health benefits applying universally.

• International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnoses.

• The four classifications (i.e., Inpatient, outpatient, prescription drug, emergency care).

The Oregon Mapping guide is available at: https://www.oregon.gov/OHA/HSD/OHP/Pages/MH-Parity.aspx

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Oregon Mapping Guide: Benefits Defined

• MH Benefits: Benefits for items or services furnished to treat mental health conditions listed in ICD-10 Chapter 5 (F), except for: – Mental disorders due to known physiological conditions. – Mental and behavioral disorders due to psychoactive substance use.– Intellectual disabilities.

• SUD Benefits: benefits for items or services furnished to treat substance use disorder conditions listed in ICD-10 Chapter 5 (F) subchapter 2 (mental and behavioral disorders due to psychoactive substance use)

• M/S Services: Benefits for items and services furnished to treat all other ICD-10 diagnoses

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2020 MHP Analysis Classifications

The four classifications of services were expanded in the 2018 MHP analysis to include six specific categories of NQTLs in the OHP delivery system in which comparability and stringency were applied:• Section I: Utilization management limits applied to inpatient services

• Section II: Utilization management limits applied to outpatient services

• Section III: Prior authorization for prescription drug limits

• Section IV: Provider admission – closed network

• Section V: Provider admission – network credentialing

• Section VI: Out-of-Network/Out-of-State limits

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Comparability and Stringency Analysis

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Comparability and Stringency Standard Question AppliedNQTL Benefits in Which NQTLs Apply To which benefits is an NQTL Assigned?

Comparability of Strategy Why is the NQTL assigned to these benefits?

Comparability of Evidentiary Standard What evidence supports the rationale for the assignment?

Comparability of Processes What are the NQTL procedures?

Stringency of Strategy How frequently or strictly is the NQTL applied?

Stringency of Evidentiary Standard What standard supports the frequency or rigor with which the NQTL is applied?

The 2018 MHP Analysis assessed each NQTL category using pre-defined comparability and stringency standards and questions.

Summary of 2020 MHP Analysis Results

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Most CCOs had achieved MHP demonstrating integrated utilization/provider admission policies and standardized evidence, encompassing MH/SUD and M/S with exception to the following:• Retrospective review (RR) and inter-rater reliability (IRR) testing failed to

meet parity in benefit packages CCOE and CCOG due to OHP FFS adjusting policies to allow 90-day RR review and an 80% IRR testing standard.

• A handful of CCOs received non-parity related findings for data revealing higher denial rates for MH/SUD service authorizations and provider credentialing denial/applications not accepted.

Improvement Plan Development

• OHA published 2020 MHP Analysis results in April 2021 on OHA’s MHP website accessible at:https://www.oregon.gov/OHA/HSD/OHP/Pages/MH-Parity.aspx

• HSAG is coordinating with the CCOs on improvement plans to address findings:

– HSAG conducted an initial review to determine the extent to which interventions or action plans would mitigate each finding (4/16/21).

– CCOs will implement respective interventions or action plans to resolve all 2020 MHP Analysis findings, providing documentation to demonstrate compliance with MHP requirements by June 1, 2021.

– HSAG will conduct a review of the CCOs’ final implementation of interventions and action plans to ensure full compliance.

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2020 MHP Analysis Recommendations

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Based on the 2020 MHP Analysis, HSAG made the following recommendations to OHA:

• General Activities:– OHP FFS collaboration with CCOs on operational changes that impact MHP.

– Annual attestations of continued compliance with MHP regulations.

– Development of material change criteria to identify triggers for MHP analysis.

• Records Review Activities:– 2021 ABD record reviews to further understand UM impacts on parity.

– 2022 MHP Provider validation records reviews to fully assess the validation of unlicensed MH/SUD provider qualifications.

– 2023 MHP claims denial records analysis to determine, in operation, whether parity exists in claims processing operations across the CCOs and OHP FFS.

2021 MHP Analysis Overview and Process (Protocol)

2021 MHP Analysis Components

HSAG was tasked to conduct a 2021 MHP analysis to determine if existing benefits and any NQTLs remain compliant with the MHPAEA and 42 CFR §438 Subpart K. The analysis will include two main components:

• Annual Attestation - A review of attestations completed by CCOs and OHP FSS intended to certify continued compliance with MHP requirements and provide information on operational changes that may impact parity.

• Records Review – An analysis of a sample of CCO and OHP FFS adverse benefit (ABD) records encompassing both MH/SUD and M/S denials to further understand utilization management details and their impact on parity.

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Protocol and Tools

The 2021 MHP Protocol describes the analysis process, tools employed to conduct the analysis, and required documentation.

• MHP Analysis Background

• 2021 MHP Analysis Activities

• 2021 MHP Analysis Tools and Documentation

• 2021 MHP Analysis Methodology

• Documentation Submission

• MHP Analysis Reporting and Improvement Plan

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Analysis Considerations

The 2021 MHP Analysis will consider:• Operations related to the delivery of benefits under enrollment

packages CCO A, CCO B, CCO E, and CCO G as referenced in the Oregon Mapping Guide (e.g., policies and delegation agreements).

• The six categories of NQTLs from past analyses.

• Operational changes since the 2020 Analysis (9/1/20 – 5/31/21).

• Whether adverse benefit determinations follow procedure.

Six Categories of NQTLs

Section I: Utilization management limits applied to inpatient services

Section II: Utilization management limits applied to outpatient services

Section III: Prior authorization for prescription drug limits

Section IV: Provider admission – closed network

Section V: Provider admission – network credentialing

Section VI: Out-of-Network/Out-of-State limits

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2021 MHP Analysis Process and Timeline

MHP Activity DateDistribution of 2021 MHP Protocol April 19, 2021

Activity Overview Webinar April 19, 2021

Documentation Submission June 1, 2021

HSAG Desk Review and Analysis June 1, 2021 – July 30, 2021

ABD Record Selection Distribution to CCOs and OHP FFS June 11, 2021

CCOs and OHP FFS Submission of Selected ABD Records July 1, 2021

Conduct WebEx Conferences with CCOs and OHP FFS August 2, 2021 – August 13, 2021

Draft 2021 MHP Report Distribution for CCO/OHP FFS Review August 2, 2021 – September 3, 2021

CCO/OHP FFS Feedback on Draft 2021 MHP Report to HSAG September 17, 2021

Final 2021 MHP Report Distribution to CCO/OHP FFS September 30, 2021

Coordination of Follow-Up Activities as Necessary October 2021

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Required Submissions

Each CCO and OHA must submit the following for the review period of September 1, 2020 - May 31, 2021:

• Completed attestation and supporting documentation for any changes identified.

• List of all inpatient and outpatient adverse benefit determinations for both MH/SUD and M/S benefits.

• Selected ABD inpatient and outpatient records.

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Attestation

The annual attestation includes questions related to:

• Changes to delegation agreements and medical guidelines/evidence used for utilization management.

• Changes to inpatient, outpatient, and/or prescription drug utilization management.

• Changes in provider admission operations and criteria.

• Changes to out-of-network/out-of-state limits.

• Enhancements made to improve the quality of MH/SUD services and/or benefit determinations.

Each CCO and OHP FFS will be required to sign and date the attestation.

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Attestation, Continued…

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ABD Record List

Each CCO and OHP FFS is required to submit a list of all inpatient and outpatient records for both MH/SUD and M/S benefits in a MS Excel format, containing specified data fields.

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Desk Review

HSAG’s desk review will include:

• Contacting CCOs/OHP FFS if information is missing or incomplete.

• Developing a randomized sample selection of submitted ABD lists including 10 MH/SUD and 10 M/S records.

• Reviewing attestations and supporting documentation to identify and assess changes to operations that may impact MHP.

• Documenting gaps in preparation for conference calls.

Once documentation (i.e., attestation and record list) is submitted by June 1, 2021, HSAG will begin a desk review.

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Submission of ABD Records

HSAG will communicate sample selection lists by June 11, 2021. Each CCO and OHP FFS will be required to submit the selected sample of records by July 1, 2021, including:• System screen shots to provide a complete record of the adverse

determination, that includes documentation of:

– Each reviewer and their credentials.

– Dates of each review.

– Communication between reviewers and utilization management staff.

– Communication between utilization management staff and members/authorized representatives.

– Communication between utilization management staff and requesting providers.

• Copies of written communication with members, authorized representatives, and requesting providers.

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Scheduled Conference Calls

HSAG will coordinate with each CCO and OHA to schedule and conduct conference calls to discuss preliminary analysis findings and gaps in areas that may require clarification. HSAG will:

• Schedule conference calls for a duration of two hours.

• Request additional information and documentation as necessary to support MHP.

• Assess information obtained during scheduled conference calls for incorporation into analysis results.

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2021 MHP Analysis Methodology

HSAG will analyze completed attestations and ABD record using both qualitative and quantitative methods:

• Attestation – Qualitative

HSAG will review and document attestation completeness, identifying changes reported to determine whether changes impact parity or require further analysis.

• ABD Records – Qualitative and Quantitative

HSAG will review and document ABD record elements, and score specified elements for alignment with operational requirements and adherence to operational processes/evidence.

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Attestation Analysis Elements

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ABD Records Review Elements

HSAG’s review of ADB records will focus on:• Adherence to CCO UM

policies and procedures.

• Use of identified evidentiary standards - not appropriateness of medical decisions.

• Level of information provided in NOABDs.

• Comparability and stringency related to UM across both benefit types (i.e., MH/SUD versus M/S).

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Comparability and Stringency Analysis

Comparability and Stringency Standard Question DescriptionBenefits in Which NQTLs Apply

To which benefits is an NQTL Assigned?

Purpose: To describe the NQTL assigned to MH/SUD and M/S benefits (e.g., prior authorization, scope of services, time frames).

Comparability of Strategy Why is the NQTL assigned to these benefits?

Purpose: To describe for what reasons or purpose the NQTL is assigned (e.g., ensure medical necessity, prevent overutilization, comply with state and federal requirements, etc.).

Comparability of Evidentiary Standard

What evidence supports the rationale for the assignment?

Purpose: To describe the evidence to support the rationale (e.g., benchmarks, standards that form the basis of the rationale, state and federal requirements, etc.).

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Comparability and Stringency Analysis

Comparability and Stringency Standard DescriptionComparability of Processes

What are the NQTL procedures?

Purpose: To describe the NQTL process and evidence needed to support NQTL determinations (e.g., documentation requirements, timelines, steps for the CCO and members/providers, etc.).

Stringency of Strategy How frequently or strictly is the NQTL applied?

Purpose: To describe the frequency of application, frequency of medical necessity and appropriateness reviews, level of discretion in how the NQTL is applied, triggers for review and re-review, etc.

Stringency of Evidentiary Standard

What standard supports the frequency or rigor with which the NQTL is applied?

Purpose: To describe standards that the CCO uses to determine the frequency or rigor of NQTL procedures.

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2021 MHP Reporting

The 2021 MHP Analysis reporting will include:

• A report to OHA documenting aggregated results of the analysis of attestations and ABD records.

• The identification of areas in which MHP has not been achieved and required actions to ensure parity.

• A review period of two weeks for each CCO and OHP FFS to provide feedback prior to finalization.

• Improvement plan guidance.

Key Reporting Dates

Draft Report Distribution: September 3, 2021

CCO/OHP FFS Feedback Due: September 17, 2021

Final Report Distribution: September 30, 2021

Documentation Submission

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Documentation Submission Requirement

By June 1, 2021:

• MHP Annual Attestation and supporting documentation.

• List of all MH/SUD and M/S inpatient and outpatient ABDs.

CCOs must submit this documentation to the OHA deliverables mailbox at CCO.MCODeliverableReports@dhsoha.state.or.us, whereas OHP FFS must submit to HSAG’s secure file transfer site at https://safe.hsag.com/.

By July 1, 2021:

• Selected ABD records.

Both the CCOs and OHP FFS must submit ABD records to HSAG’s secure file transfer site at https://safe.hsag.com/.

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Documentation Submission Instructions

When submitting documents, OHA and CCOs should:‒ Upload documents to the appropriate folder (MH Parity).‒ Include searchable documents to the extent possible.‒ Limit the length of the filename of uploaded documents.‒ Ensure document file names reflect the content.

Requesting access to and questions related to HSAG’s SAFE site can be directed to the following HSAG staff:

Ivan Kuletz503.583.5487

ikuletz@hsag.com

Crystal Brown720.697.7907

cbrown@hsag.com

Pending Legislation

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House Bill (HB) 3046

HB3046 seeks to address MHP by requiring:• Insurers and CCOs to submit MHP compliance analyses to the

Department of Consumer and Business Services and OHA.

• The use of generally accepted standards of care when making medical necessity determinations and level of care placement decisions (e.g., ASAM and American Psychiatric Association’s Clinical Practice Guidelines).

• Demonstrated access to MH/SUD providers.

• Treatments to address underlying causes and treating serious and persistent mental illness and SUDs as chronic conditions, rather than solely focusing on acute crisis levels of care.

• OHA to adopt by rule a list of benefits that may not be subject to prior authorization.

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House Bill (HB) 3046, Continued…

More specifically for OHA, HB3046 will require:

• CCOs to report, by June 1st each year, MHP compliance information including but not limited to:– Coverage terms and NQTLs applied to MH/SUD and M/S benefits.

– Processes, strategies, evidentiary standards, and other factors used to apply NQTLs.

– The number of denials of coverage for MH/SUD services, including appeals.

– The percentage of claims paid to providers for MH/SUD versus M/S services.

– Network adequacy and timeliness of access to MH/SUD services.

• OHA, based on CCO documentation and in collaboration with MH/SUD consumers and community mental health programs, to identify and assess MHP, issuing a report to the Legislature.

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Current Status of HB3046

HB3046 -4 amendment to be moved to the Joint Committee on Ways and Means; no strong opposition noted.

• OHA consulted with legislative staff to discuss analyses conducted over the last few years and the direction of future analyses.

• Both OHA and HSAG are watching this legislation closely and will determine its impact as enrolled.

• If enrolled, the legislation will become effective July 1, 2021. This will impact MHP analyses for 2022 and beyond - No impact in 2021.

Questions and Answers

HSAG is available to provide technical assistance throughout the MHP Analysis activity.

Thank you!

Melissa Isavoran, Associate Executive Director

misavoran@hsag.com | 503-839-9070

Amy Lewis, Director

alewis@hsag.com | 602-527-3535

Contact Information

Oregon’s EQRO website: https://www.hsag.com/en/myoregoneqro/