The Evolution of Mental HealthcareMind-body Integration improves

patient outcomes and reduces cost

Healthcare Reform• Payment streams for psychiatric and substance use care are distinctive and poorly understood

• Scope of the relative sectors – public, commercial, direct state expenditures, self pay are unique

• Substantial impact of medical and psychiatric co- morbidity on total cost of all medical care

Guiding Principles for Reform: The Triple Aim

• Improving the patient experience of care (including quality and satisfaction)

• Improving the health of populations

• Reducing the per capita cost of health care

THE LONG TERM COSTS OF HEALTHCARE –PUBLIC AND PRIVATE ARE UNSUSTAINABLE

Treat Mental Illness Like Every Other Disease

CHECK UP FROM THE NECK UP

Mental Health Parity

The Mental Health Parity and Addictions Equity Act (MHPAEA) requires group insurers to ensure that the “financial requirements” and “treatment limitations” that are applicable to mental health and substance abuse use benefits are no more restrictive than the predominant financial requirements and treatment limitations for medical and surgical benefits covered by the plan.

Parity for co-payments, visit limits, etc.

• Key Concepts• Benefit Classification (Six Coverage Categories)– IP In Network; IP out of Network– OP In Network; IP Out of Network– Emergency– Rx

• If MH/SUD benefits are covered within any of these categories they must be covered in all categories that general medical benefits are covered

Financial Requirements and Treatment Limits (e.g. visit limits)

• To assess whether parity requirements are met one applies the substantially all (66%) and predominant (50%) tests within a coverage category (inpatient in-network) for medical-surgical

• The substantially all test is applied first to determine whether a co-payment or co-insurance is the financial requirement that applies to substantially all spending

• The predominant test is then applied to determine what level of financial requirement must be in place for behavioral health (e.g. 20% co-insurance)

SUBSTANTIALLY ALL

A financial requirement or quantitative treatment limitation applies to substantially all medical/surgical benefits in a classification if it applies to at least two-thirds of the benefits in that classification.

PREDOMINANT

The predominant level of a type of financial requirement or quantitative treatment limitation is the level that applies to more than one-half of medical/surgical benefits in the classification. If no single level applies to more than one-half of medical/surgical benefits subject to a financial requirement or treatment limitation in a classification, plan payments for multiple levels of the same type of financial requirement or treatment limitation can be combined.

5 Parity Law Facts1. Parity law only applies to plans that provide mental health benefits.

The law does not require plans to provide mental health benefits if they did not already.

2. Residential treatment and intensive outpatient treatment are included as intermediate levels of care for parity.

3. Plans must use the same type of authorization and utilization review process for both mental health and medical services

4. Federal parity law applies to self funded and fully insured large group plans with greater than 50 or 100 employees. A small employer is defined as one that has 100 or fewer employees, but States have the option to use 50 employees rather than 100 for 2014 and 2015.

5. State parity laws are not preempted by the federal parity law. You may seek proper coverage under state and/or federal parity laws.

Parity Victory!

• NY Attorney General Eric T. Schneiderman announced Cigna Corp. is required to reprocess and pay hundreds of claims for nutritional counseling for mental health conditions, including eating disorders, to members who were wrongfully denied access to those benefits.

• NY state’s parity law mandates that health insurance companies must provide mental health benefits on par with other medical benefits.

• Cigna violated this law and limited the number of nutritional counseling sessions to only three visits for patients with mental health conditions while placing no limits on nutritional counseling visits for those with medial or physical diseases.

Factors for Integrating Behavioral Health

• Increasing Health Coverage, including Behavioral Health– The ACA provides new or expanded behavioral health

coverage to 60 million Americans.– Health plans offered through state and federal marketplaces

are required to offer behavioral health services and comply with MHPAEA

– Under the ACA, preventive screening and routine checkups must be provided with no copays or deductibles.

– Insurers can no longer deny coverage for pre-existing conditions, including behavioral health disorders.

– Adults up to age 26 can stay on their parents insurance plans.

Factors for Integrating Behavioral Health

• Decreasing the Total Cost of Care– Long-term cost savings are attractive to

organizations that seek to achieve the Triple Aim– People with untreated behavioral illness drive up

total health care costs because they use non-psychiatric inpatient and outpatient services 3 times more than those who receive treatment.

– Individuals with comorbid physical and behavioral conditions are at heightened risk of being readmitted

Factors for Integrating Behavioral Health

• Managing a Population’s Health– People with a serious mental illness die 25 years

earlier on avg. than the general population– Half of Americans develop a behavioral illness

during their lifetime– Mental disorders account for 23% of years lived

with disability– Behavioral illnesses and substance abuse annually

cost U.S. employers an est. $80 to $100 billion annually in indirect costs

For more information visit:

www.thekennedyforum.org

www.patrickjkennedy.net

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