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Mental Health Parity, the ACA, & Californians with Mental Health Challenges.
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Transcript of Mental Health Parity, the ACA, & Californians with Mental Health Challenges.
Mental Health Parity, the ACA, & Californians with Mental
Health Challenges
What this training will cover
I. Stigma Faced by People with Mental Health Disabilities
II. Overview of Mental Health Parity –Existing Federal & State Laws
III. Overview of the Affordable Care Act – New Federal and State Laws
IV. Intersection of Parity & ACA in California
V. How the Laws Can Reduce Stigma and Discrimination
Stigma
Stigma faced by people with mental health challenges
Stigma refers to attitudes and beliefs that lead people to reject, avoid, or fear those they perceive as being different.
Discrimination faced by people with mental health challenges
Unjust deprivation of rights and opportunities due to stigma
- exclusion or marginalization of people
- denial of equal health / insurance benefit
- less chance of full participation in life
What is mental health parity?
Parity ends disparity or unequal physical and mental health insurance coverage
Parity = Equality
Examples of No Parity
Equality of Copayments
1. Different levels of co pays are banned
2. $15 for outpatient physical health visit
3. $20 for outpatient mental health visit
Equal Treatment Lengths
1. Different levels of an treatment limits are banned
2. 21 inpatient days for mental health care
3. 30 inpatient days for physical health care
California Mental HealthParity Act
Health care plans issued, amended or renewed on or after July 1, 2000 provide coverage for the diagnosis and treatment of specified mental health conditions under the same terms and conditions applied to other medical conditions.
Cal. Health & Safety Code § 1374.72(a)
People protected under CA parity
- Children with serious emotional disturbances- People with serious mental illnesses (SMI),
which are defined to include: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa
Cal. Health & Safety Code § 1374.72(d)
Equal terms and conditions
Include but not limited to the following:
1. maximum lifetime benefits
2. copayments
3. individual and family deductibles.Cal. Health & Safety Code § 1374.72(c)
Benefits that must be provided
Include:
1. outpatient services
2. inpatient hospital services
3. partial hospital services
4. prescription drugs, if the plan contract includes coverage for prescription drugs.
Cal. Health & Safety Code § 1374.72(b)
All “medically necessary” treatment
9th Circuit found that California parity law requires that a health plan provide all “medically necessary treatment” for “severe mental illnesses,” such as: residential care for an individual with anorexiaHarlick v. Blue Shield of California 686 F.3d 699 (2012)
Federal parity law
Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
Federal parity regulations
Equal financial requirements and treatment limitations between mental health / substance abuse disorder benefits and medical/surgical benefits.
See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal Register, Vol 78, No.219 68240-68296 (Nov. 13, 2013) [Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]
Equal terms and conditions
- Quantitative: co-pay, deductibles, number of visits, lifetime caps
- Non-quantitative: utilization review, formulary design, step therapy
See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal Register, Vol 75, No.21 5410-5451 (Feb. 2, 2010) [interim final rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]
CA & Federal Parity Laws
CA Federal
Specified Diagnoses Y N
Specified Benefits Y N
Federal parity law requires equality if any mental health or substance use disorder benefits are covered.
Federal parity: 6 benefit classes
1. inpatient, in-network
2. inpatient, out-of-network
3. outpatient, in-network
4. outpatient, out-of-network
5. emergency care
6. prescription drugs.
See: Federal Register Vol. 75, No. 21 5413
Benefit coverageby federal parity
Coverage provided for mental health and substance abuse disorder benefits in each classification in which medical/surgical coverage is provided.
See: Federal Register Vol. 75, No. 21 5413
Do federal parity rules define inpatient, outpatient or emergency care?
No. Fed parity regulations say plan terms defining benefits must be consistent with generally recognized standards of medical practice. Plan must apply terms uniformly.
See: Federal Register Vol. 75, No. 21 5413-5414
What is the Affordable Care Act (ACA)?
The Patient Protection & Affordable Care Act of 2010 (ACA) = “Obama-
Care”
What are the goals of the Affordable Care Act?
Goal 1: Strengthen Health Care
Objective A: More secure coverage for those insured & extend
affordable coverage to uninsured
Objective B: Improve healthcare quality and patient safety
Objective C: Emphasize primary and preventive care linked
with community prevention services
Objective D: Reduce the growth of healthcare costs while
promoting high-value, effective care
Objective E: Ensure access to quality, culturally competent
care for vulnerable populations
Objective F: Promote the adoption and meaningful use of
health information technology
Source: http://www.hhs.gov/secretary/about/goal1.html [includes other goals]
How does ACA extend affordable coverage to the uninsured?
How does ACA extend affordable coverage to the uninsured?
1. Public Medicaid (Medi-Cal in California) Expansion2. Private Plans on health insurance
“Exchanges”
a. Individual Mandate
b. Employer Mandate
Will Medi-Cal expand?
California plans to increase Medi-Cal eligibility to single, childless adults up to 138% of federal poverty level
Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13) at: http://abgt.assembly.ca.gov/sites/abgt.assembly.ca.gov/files/March%206%20-%20Affordable%20Care%20Act%20Medi-Cal%20Expansion.pdf
Benefits of Medi-Cal Expansion
1. Insure over 1 million Californians
2. 100% fed $ for 3 yrs, then over 4 yrs up to 10% state match
3. More insured people improves public health for all in CA
4. Infuses millions, possibly billions, of fed $ in CA
5. Insure more people nationally = market stability & cost control
Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13)
What are health insurance Exchanges?
What are Health Insurance Exchanges?
Organizations set up to help individuals and small businesses purchase health insurance policies
“Covered California” is the exchange in CA
What is the individual mandate?
Most Americans must get health coverage
Penalty phased in 2014 through 2016
Exempts certain individuals
What is the employer mandate?
ACA responsibilities apply to employers with 50 + employees
Penalty for failure to offer minimum essential coverage to employees
Implementation in 2015
Other ACA provisions include
1. Subsidies
2. Pre-existing condition coverage
3. People under age 26 covered on parental insurance
Source: http://www.hhs.gov/secretary/about/goal1.html
Intersection of Mental Health Parity & the ACA for Californians with Mental Health
Challenges
ACA Plans must comply with federal parity law & provide 10 “essential health benefits”
Essential benefits
1. Ambulatory
2. Emergency
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative & habilitative
8. Laboratory
9. Preventative, wellness, chronic disease management
10. Pediatric services, including oral and vision care
See http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html
California has adopted Kaiser HMO Plan as benchmark
Includes following mental health coverage:– Outpatient mental health services– Inpatient hospital and intensive psychiatric
treatment programs (includes crisis residential treatment)
CA benchmark coverage
Services are for the diagnosis or treatment of Mental Disorders…identified as a "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM) that results in clinically significant distress or impairment of mental, emotional, or behavioral functioning.
Kaiser Small Group HMO Plan 1637, Plan 30-N, p.33 (Aug. 15, 2011)
Medi-Cal Expansion
1. Provide same array of mental health services to individuals currently eligible: Specialty Mental Health Services
2. Provide benchmark /10 essential health benefits
Parity & ACA can reduce stigma and discrimination
“Stigma is the most formidable obstacle to progress in the arena
of mental illness and health.”
Prevention & Wellness Care
1. Help people recognize early signs
2. Connect with support and services
3. Improved Outcomes -a. Reduce homelessness
b. Increase employment
c. Avoid unnecessary criminal justice involvement and hospitalization
Rehabilitation & Recovery
1. Individualized Services
2. Peer Support
3. Self-Help or Consumer-run Services
4. Cultural & Linguistic Competence
5. Improved Outcomes -a. Help people attain their goals
b. Support living in most integrated setting
Policy Paper on Recovery-Focused Hospital Diversion & Aftercare
1. Best practices on pathways to home & community services
2. Cost and quality analysis of model crisis alternatives to hospitalization
3. Recovery-based policy recommendations
4. Coordination between private plans and the public mental health system
Alternatives to Acute Hospital
- Outreach / Prevention- Crisis Lines / Crisis Clinics- Mobile Crisis Intervention- Crisis Stabilization Units / Urgent Care Units- Crisis Residential Treatment Facilities- Crisis Respite- Integrated Services
– Full Service Partnership (FSP)– Assertive Community Treatment (ACT)– Wraparound– System of Care
Disclaimer
This area of the law is rapidly developing. These provisions are not intended to include all federal and state laws, regulations, policy directives or other relevant references. Further legal research is required. The intent here is to provide a general overview of these topics.
Disability Rights California isfunded by a variety of sources, for a
complete list of funders, go to http://www.disabilityrightsca.org/
Documents/ListofGrantsAndContracts.html.
CalMHSA
The California Mental Health Services Authority
(CalMHSA) is an organization of county governments
working to improve mental health outcomes for
individuals, families and communities. Prevention and
Early Intervention programs implemented by CalMHSA
are funded by counties through the voter-approved
Mental Health Services Act (Prop 63). Prop. 63 provides
the funding and framework needed to expand mental
health services to previously underserved populations
and all of California’s diverse communities.