FEDERAL MENTAL HEALTH PARITY

SLEEPLESS IN SAINT LOUIS

Peter A. Ambrose, Jr., Ph.D., M.B.A.Regional Vice President, WellPointBehavioral Health Operations

CONSIDERATIONS• Covered Diagnoses

• Treatment Limits; Financial Limits

• Specialist / Non-Specialist Designation

• Clinical Management Strategies

• Operational Implementation

• Cost of Care Implications

COVERED DIAGNOSES

• Act does not mandate coverage.• Act does not mandate coverage of all Mental

Health conditions.• State mandates may have specific guidance.• Intention of defined eligible diagnoses should

be vetted.

TREATMENT LIMITS; FINANCIAL LIMITS

• Treatment Limitations – can’t be more restrictive than the “predominant” treatment limits applied to medical, with no separate treatment limitations.

• Financial Requirements may not be more restrictive than “predominant” financial requirements applied to medical.

• Can MH/SA be better?• Are there comparable treatment

modalities/service levels?– RTC vs. SNF?– IOP/PHP vs ???

SPECIALIST / NON-SPECIALIST DESIGNATION

• Is a Mental Health professional comparable to a PCP or a Specialist? Issue of co-pay.

• Unintended Consequences– Utilization– Operations Issues

CLINICAL MANAGEMENT STRATEGIES

• Opportunity exists to medically manage benefit.

• Must disclose Medical Necessity Criteria to members and providers.

• Manage outpatient services efficiently – outlier review.

• Manage all facility-based services.• Manage state mandates closely.• Case Management and Disease Management

programs.• Health Service Codes review.• Tier Professional Network.

OPERATIONAL IMPLEMENTATION• Business Units• Legal• Behavioral health• Project Management• IT• Product Management• Compliance• Account Management• Operations• Marketing – Communications• Actuarial• Underwriting

COST OF CARE IMPLICATIONS• Behavioral Health cost of care typically = 3% to

4% total of medical• Projected average BH cost of care increase

related to Parity*:

• Relative BH cost of care increase based on benefit starting position*:

*Milliman Cost of Care Guidelines

10% 0% BH IP0.6% to 1.0% 0.1% Overall Medical Cost of Care

30% 3% BH OPWithout UMWith UM

10% 0% BH IP0.6% to 1.0% 0.1% Overall Medical Cost of Care

30% 3% BH OPWithout UMWith UM

30 v unlimited = 6.5% 50 v unlimited = 1.1% OP60 d unlimited = 1.2% 30 d unlimited = 2.4% IP

30 v unlimited = 6.5% 50 v unlimited = 1.1% OP60 d unlimited = 1.2% 30 d unlimited = 2.4% IP

• In summary . . . COC Impact Depends!