August 10, 2017
John R. Graham
Acting Assistant Secretary for Planning and Evaluation
200 Independence Avenue SW Room 424E
Washington, DC 20201
Dear Mr. Graham:
On behalf of the American Society of Addiction Medicine (ASAM), a national medical specialty society representing more than 4,700 physicians and allied health professionals who specialize in the treatment of addiction, thank you for the opportunity to provide input on Strategies for Improving Parity for Mental Health and Substance Use Disorder Coverage.
Thorough implementation and strong enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) is essential to ensuring the tens of millions of Americans suffering from addiction and mental illness can access the treatment they need. We offer the recommendations below based on our members’ collective experience providing treatment services to patients with addiction and hope they will inform the Administration’s efforts to strengthen parity enforcement and improve consumers’ and providers’ awareness of their protections under the law.
While some administrative progress has been made in recent years to expand access to evidence-based addiction treatment, too often patients who seek addiction treatment face barriers that they would not face for any other chronic disease. One of the most critical issues is limited or lacking insurance coverage of evidence-based therapies such as medications for opioid addiction and needed psychosocial supports. If a patient needs treatment and is ready to seek it, restrictive payer policies should not prohibit access to the kind of care we know works, but far too often that is the case. Recommendations to address this inequity include:
Transparency and Disclosure. One of the most common barriers reported by the patients ASAM members serve is the lack of disclosure by health plans on the development and application of Non-Quantitative Treatment Limits (NQTLs). Parity compliance testing cannot be performed on coverage limitations such as prescription drug formulary design, medical and administrative management techniques, including restrictions based on facility type or provider specialty, without this information. For example, in order to determine whether a plan is in compliance with the law, consumers and their providers, who often serve as authorized representatives for patients, may request medical management criteria and protocols, information on how these criteria and protocols are developed and applied (both as written and in operation), for both MH/SUD and medical/surgical benefits. The timely disclosure of this information is essential to be able to determine whether a plan is compliant with or in violation of MHPAEA’s NQTL rule.
Recommendations
- To ensure documents and information are fully disclosed, consistent with MHPAEA’s statute and implementing regulations, we recommend regulators develop template forms showing the plan’s NQTL parity compliance analysis and require the documents and information outlined in Attachment A to be supplied for review upon request by regulators, patients, and authorized patient representatives.
- Parity regulatory guidance required under the 21st Century Cures Act on non-quantitative treatment limitations and other issues should be issued as soon as possible, but no later than the statutory deadline of December 2017.
- Federal and state regulators should use random plan audits to improve compliance.
- Consistent with the requirements in the 21st Century Cures Act, regulators should audit plans with at least 5 violations based on allegations of non-compliance with MHPAEA.
- All enforcement actions and compliance correction plans should be made public on appropriate federal and state websites.
- Denial rates for each benefit classification for MH/SUD and medical/surgical for group health plans should be tracked, collected, and made public on state and federal websites (including the plan’s methodology for classifying and tracking such denial rates).
- As required by the 21st Century Cures Act, the Centers for Medicare and Medicaid Services (CMS) and DOL’s Employee Benefits Security Administration (EBSA) should issue a report on parity compliance and federal investigations of parity non-compliance. Such a report should include market data providing indications of compliance and non-compliance, rather than merely complaint-driven reporting.
Consumer and Provider Understanding of Rights and Benefits under MHPAEA.There is limited public awareness of health plan enrollees’ rights and benefits under the parity law. A survey by the American Psychological Association found that only 4% of Americans said they were even aware of MHPAEA. Neither the Administration nor health plans have engaged in any major public awareness campaigns to inform enrollees about the law. The Substance Abuse and Mental Health Services Administration (SAMHSA) has provided information on its website and DOL and Center for Consumer Information and Insurance Oversight (CCIIO) have help lines, but the information provided on the help lines to consumers is too complicated and overly comprehensive for them to understand (e.g., legislative background on HIPAA and MHPAEA). In certain states, state officials have told enrollees that the state is not required to implement or enforce MHPAEA and have outdated information on their website about the law.
Given that the limited enforcement of the law to date has relied on consumer complaints, this lack of public awareness exacerbates the problems with enforcement. As only those who know and understand their rights can complain, complaints are limited and thus enforcement is sparse. Increasing consumer awareness and understanding is another strategy to improve enforcement by driving complaints.
Finally, we have also found that when plan members are aware of the parity law and believe a plan has violated it, they struggle with how and where to file a complaint given the myriad of federal and state entities with enforcement authority over MHPAEA.
Recommendations
- An interactive consumer parity portal on relevant state and federal websites should be developed within 6 months to allow consumers to easily access all publicly available parity information and submit complaints to a central online clearinghouse. A public education campaign should accompany the release of the interactive portal to make patients and providers aware of the resource.
- A training curriculum for consumers on MHPAEA for DOL, the CCIIO and stakeholders should be developed and geared towards 9th grade level of education. Regional or onsite technical assistance must be available upon request.
- Agencies should clarify how MHPAEA applies across various plan types including, appeals rights, timelines, and agency responsible.
Conclusion
Thank you again for the opportunity to provide comments. We look forward to working with the T Administration in any way we can to ensure MHPAEA’s full implementation and enforcement, so that patients can access the addiction treatment services promised under the law.
Sincerely,
Kelly J. Clark, MD, MBA, DFASAM
President, American Society of Addiction Medicine
