An Independent Licensee of the Blue Cross and Blue Shield Association

Federal Mental Health ParityFederal Mental Health ParityBruce R. Croffy MD, PhDBruce R. Croffy MD, PhD

Medical DirectorMedical DirectorBlue Cross of IdahoBlue Cross of Idaho

August 27August 27thth, 2009, 2009

Overview Federal Mental Overview Federal Mental health Parity Acthealth Parity Act

• Signed into law 10/3/08 as part of “bail out” bill.Signed into law 10/3/08 as part of “bail out” bill.• 1996 Mental Health Parity Act required parity 1996 Mental Health Parity Act required parity

only for lifetime and annual limits.only for lifetime and annual limits.• Clearly allowed plans to limit annual visits or Clearly allowed plans to limit annual visits or

number of treatment days and apply distinct number of treatment days and apply distinct cost sharing requirements.cost sharing requirements.

• The current Act addresses disparities in The current Act addresses disparities in treatment and financial limits for mental health treatment and financial limits for mental health and substance use disorder benefits. and substance use disorder benefits.

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What the Act does What the Act does NOTNOT do do

• It is not a mandate to provide mental It is not a mandate to provide mental health or substance abuse benefitshealth or substance abuse benefits

• It does not mandate coverage of all It does not mandate coverage of all mental health conditionsmental health conditions

• It does not eliminate medical It does not eliminate medical management.management.

• It does not affect small employers (50 It does not affect small employers (50 or fewer employees)or fewer employees)

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New Parity RequirementsNew Parity Requirements

• Mental Health/Substance Abuse (MHSA) Mental Health/Substance Abuse (MHSA) provisions must be no less restrictive than the provisions must be no less restrictive than the medical/surgical benefitsmedical/surgical benefits

• Financial parity requires the same deductibles, Financial parity requires the same deductibles, co-payments, coinsurance and out-of-pocket co-payments, coinsurance and out-of-pocket expenses.expenses.

• Health Plans may still have an aggregate Health Plans may still have an aggregate lifetime limit and aggregate annual limit that is lifetime limit and aggregate annual limit that is applied to both medical and MHSA benefits applied to both medical and MHSA benefits

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Out-of-Network BenefitsOut-of-Network Benefits• Plans are required to provide out-of-network Plans are required to provide out-of-network

mental health and substance abuse benefits if mental health and substance abuse benefits if the plan provides out-of-network medical/ the plan provides out-of-network medical/ surgical benefits. surgical benefits.

• Health plans would match out-of-network Health plans would match out-of-network medical/surgical benefit with out-of-network medical/surgical benefit with out-of-network mental health and substance abuse benefit mental health and substance abuse benefit

• Does not prevent plans from using certain out-Does not prevent plans from using certain out-of-network medical management techniques of-network medical management techniques that do not conflict with parity requirements. that do not conflict with parity requirements.

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Mental Health and Substance Mental Health and Substance Abuse CoverageAbuse Coverage

• Plans may define covered services for mental Plans may define covered services for mental health and substance abuse treatment. For health and substance abuse treatment. For example, a plan might limit the definition of example, a plan might limit the definition of mental health to exclude a set list of disordersmental health to exclude a set list of disorders

• This provision of choice allows plans to control This provision of choice allows plans to control scope and costscope and cost

• For insured plans, state laws that define For insured plans, state laws that define mental health benefits generally not mental health benefits generally not preemptedpreempted

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Medical ManagementMedical Management

• The Act does not expressly limit medical The Act does not expressly limit medical management or mandate parity in medical management or mandate parity in medical management techniques management techniques

• Plans must now disclose medical necessity Plans must now disclose medical necessity criteria to participants, beneficiaries or criteria to participants, beneficiaries or providersproviders

• Plans are allowed to preserve the rule of Plans are allowed to preserve the rule of construction that permits the definition of construction that permits the definition of policy terms and conditionspolicy terms and conditions

Groups AffectedGroups Affected

• All insured or self-insured group health All insured or self-insured group health plans with a few exceptionsplans with a few exceptions

• All group health plans regulated by All group health plans regulated by Employee Retirement Income Security Employee Retirement Income Security Act (ERISA)Act (ERISA)

• ““Carve-out” plans (MHSA are managed Carve-out” plans (MHSA are managed by a separate vendor)by a separate vendor)

• Medicaid managed care plansMedicaid managed care plans8

Groups ExemptedGroups Exempted• An ERISA group health plan with 50 or fewer An ERISA group health plan with 50 or fewer

employeesemployees• An ERISA plan is exempt for one year if they An ERISA plan is exempt for one year if they

can show its total plan costs of coverage for can show its total plan costs of coverage for MHSA and medical benefits increase by at least MHSA and medical benefits increase by at least 2% in the first year of coverage after the 2% in the first year of coverage after the effective date of the acteffective date of the act

• Disability and long-term supplemental care Disability and long-term supplemental care plansplans

• Government- sponsored non-ERISA health plansGovernment- sponsored non-ERISA health plans• Indemnity plans (hospital or other fixed Indemnity plans (hospital or other fixed

indemnity plans)indemnity plans) 9

TimeframeTimeframe

Effective dateEffective date

Generally effective for plan years Generally effective for plan years beginning on or after October 3, 2009 beginning on or after October 3, 2009 (for calendar year plans = Jan 1, (for calendar year plans = Jan 1, 2010)2010)

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TimeframeTimeframe

RegulationsRegulations

• Instructs the Department of Labor, Health and Instructs the Department of Labor, Health and Human Services and Treasury to issue Human Services and Treasury to issue regulations within one yearregulations within one year

• Health plans may need to implement before Health plans may need to implement before regulations are issued therefore numerous regulations are issued therefore numerous implementation issues may not be resolvedimplementation issues may not be resolved

• Interim final regulations expected between Interim final regulations expected between late summer and fall 2009late summer and fall 2009

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Unanswered QuestionsUnanswered Questions

• Applicability of the Parity Act to Employee Applicability of the Parity Act to Employee Assistance ProgramsAssistance Programs

• Clarification as to whether other treatment Clarification as to whether other treatment limitations will be included in the lawlimitations will be included in the law

• Specifics of the interplay between state parity Specifics of the interplay between state parity mandates and federal paritymandates and federal parity

• Details of the process for filing the cost-based Details of the process for filing the cost-based exemptionexemption

• Will adherence requirements be lessened the Will adherence requirements be lessened the first year to allow plans to match benefits to first year to allow plans to match benefits to the final rulesthe final rules

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Current LandscapeCurrent Landscape

• 2009 NAMI report gives Idaho a “D” in MHSA2009 NAMI report gives Idaho a “D” in MHSA• Prior limited MHSA benefit created inaccurate Prior limited MHSA benefit created inaccurate

billing, unbundling and poor provider billing, unbundling and poor provider communicationcommunication

• Lack of integration of behavioral health Lack of integration of behavioral health services prevented holistic patient care services prevented holistic patient care approachapproach

• Distribution of MHSA services/providers Distribution of MHSA services/providers insufficient in rural Idahoinsufficient in rural Idaho

• Current levels of care often not adherent to Current levels of care often not adherent to “best practices”/evidence-based guidelines“best practices”/evidence-based guidelines

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NAMI State ScorecardNAMI State Scorecard

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Key NAMI FindingsKey NAMI Findings

• States not focusing on wellness and survival States not focusing on wellness and survival for people with serious mental illnessfor people with serious mental illness

• Private insurance plans often lack sufficient Private insurance plans often lack sufficient coveragecoverage

• States not adequately providing services that States not adequately providing services that are the lynchpins of a comprehensive system are the lynchpins of a comprehensive system of care such as integrated MHSA treatmentsof care such as integrated MHSA treatments

• States are not creating a culture of respectStates are not creating a culture of respect• Stigma of mental health remains a major Stigma of mental health remains a major

concernconcern 15

Mental Health / Substance AbuseMental Health / Substance AbuseInpatient Blue Health Intelligence Inpatient Blue Health Intelligence

DataData

Those Plans with parity have a "P" designation preceding their number. Rows with the same number represent States with more than one BCBS Plan.

Average Length of Stay

Idaho should anticipate an increase in length of stay. A majority of the Parity plans have longer lengths of stay compared with Idaho.

Admissions Per 1000

Idaho ranks toward the midpoint of Parity plans in Admissions Per 1000.

4-5% of inpatient MHSA cases exceed the 30 day inpatient maximum seen in many health plans

All BHI Plans

Commercial PPOClaims Incurred 10/1/2007 to 9/30/2008

Average Length of Stay   Admissions Per 1000P25 4.79 P25 0.69

4 4.86 P31 1.46P21 5.82 P1 1.65

Idaho 5.82 P21 2.174 5.85 P21 2.274 6.00 P34 2.33

P2 6.14 Idaho 2.38P16 6.15 P39 2.55P22 6.22 P2 2.63P31 6.33 P10 2.65P21 6.51 P22 2.71P34 6.65 P16 2.90

6 6.80 P33 2.94P10 6.86 10 2.99P33 6.88 6 3.00

10 6.95 4 3.0310 6.98 10 3.16

P15 7.05 4 3.253 7.06 3 3.26

P39 7.17 P15 3.2910 7.26 4 3.34P1 7.94 P18 3.54

P30 8.17 10 3.71P26 8.33 P26 3.79P18 16.18   P30 5.11 16

Mental Health / Substance AbuseMental Health / Substance Abuse Professional Blue Health Intelligence DataProfessional Blue Health Intelligence Data

Professional Visits

Both Visits per 1000 and Visits per Patient are positioned in the center of the rankings.

10-15% of outpatient MHSA visits exceed the 20 visit maximum seen in many health plans and these tend to be the most expensive ($30,000 or more/year)

Those Plans with parity have a "P" designation preceding their number. Rows with the same number represent States with more than one BCBS Plan.

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All BHI Plans

Commercial PPOClaims Incurred 10/1/2007 to 9/30/2008

Professional

Visits Per 1000 Visits Per PatientP25 122.60 P25 2.3

4 138.44 P21 2.5P1 139.05 P31 3.0

P31 182.41 P33 3.3P16 203.57 P2 3.3P21 204.50 4 3.4P33 213.72 P1 3.5

P2 221.74 10 3.76 251.66 P22 4.1

P34 272.76 P21 4.210 306.93 P39 4.2

Idaho 351.16 Idaho 4.2P22 373.47 6 4.4P21 402.68 P34 4.5

4 426.07 P26 4.8P10 432.19 4 5.1P39 433.37 4 5.3

10 476.46 10 5.44 506.24 10 5.4

P26 536.59 P10 5.910 546.48 P16 5.9

P18 670.13 P18 6.13 682.10 P30 7.1

P30 1066.36 P15 8.6P15 1132.23   3 9.1

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Best in Class ProgramsBest in Class Programs• Use of data driven algorithms to identify outlier Use of data driven algorithms to identify outlier

cases and inconsistent carecases and inconsistent care• Robust program reporting / accountability Robust program reporting / accountability • Appropriate application of medical necessity Appropriate application of medical necessity

and utilization management resultsand utilization management results• Network managementNetwork management• Provider Education/Plan PartnershipProvider Education/Plan Partnership• Integration of medical & behavioral to address Integration of medical & behavioral to address

high cost medical populationshigh cost medical populations

BH Unit Implementation BH Unit Implementation A year-long projectA year-long project

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BCI Behavioral Health UnitBCI Behavioral Health UnitFully-staffed unit integrated within BCI Fully-staffed unit integrated within BCI

MQM division providing –MQM division providing –• Uniform systems platform for claims, case management Uniform systems platform for claims, case management

and reporting on entire medical/surgical and MHSA and reporting on entire medical/surgical and MHSA benefitbenefit

• Utilization managementUtilization management• Complex case managementComplex case management• Accreditation and continuous quality improvement Accreditation and continuous quality improvement

functionsfunctions• Provider advisory panelProvider advisory panel• Pharmacy benefit management/medication adherence Pharmacy benefit management/medication adherence

programprogram• Depression disease managementDepression disease management 20

BCI Behavioral Health UnitBCI Behavioral Health Unit

• Complex Case ManagementComplex Case Management Care coordination for MHSA inpatientsCare coordination for MHSA inpatients Coordination with medical/surgical acute Coordination with medical/surgical acute

and complex case managers for cross and complex case managers for cross referralreferral

Identify gaps/barriers to optimal outcomesIdentify gaps/barriers to optimal outcomes• Assess community support servicesAssess community support services• Assess provider availabilityAssess provider availability• Decrease emergency room utilizationDecrease emergency room utilization• Coordinate care with primary physicianCoordinate care with primary physician

BCI Behavioral Health UnitBCI Behavioral Health Unit

• Disease Management for DepressionDisease Management for Depression Significant number of cases not optimally managed Significant number of cases not optimally managed

by primary care providerby primary care provider High prevalence of depression in Medicare/Medicaid High prevalence of depression in Medicare/Medicaid

population often undiagnosed/undertreated population often undiagnosed/undertreated Medication adherence critical to treatment successMedication adherence critical to treatment success Care coordination proven to maintain medication Care coordination proven to maintain medication

compliance and improve outcomescompliance and improve outcomes 8-10% of workforce affected annually with 8-10% of workforce affected annually with

depression resulting in significant absenteeismdepression resulting in significant absenteeism

BCI Behavioral Health UnitBCI Behavioral Health Unit

Special initiativesSpecial initiatives• Define provider distribution gaps within IdahoDefine provider distribution gaps within Idaho• Explore concept of Telepsychiatry and its Explore concept of Telepsychiatry and its

applicability for rural behavioral health careapplicability for rural behavioral health care• Contract and credential out-of network/state Contract and credential out-of network/state

providers to augment coverage gapsproviders to augment coverage gaps• Empower Provider Advisory Panel to address Empower Provider Advisory Panel to address

provider shortages and facilitate remediesprovider shortages and facilitate remedies• Work with advisory panel to strengthen best Work with advisory panel to strengthen best

practices for Idaho MHSApractices for Idaho MHSA