August 10, 2017
Submitted Via Email: parity@hhs.gov
Laurel Fuller
Assistant Secretary for Planning and Evaluation, HHS
200 Independence Avenue SW
Rome 424E
Washington, DC 20201
Re: Listening Session on Strategies for Improving Parity for Mental Health and Substance Use Disorder Treatment
Dear Ms. Fuller:
On behalf of Rosecrance Health Network, we submit the following comments for the public stakeholder listening session on Strategies for Improving Parity for Mental Health and Substance Use Disorder Coverage (the “Listening Session”). As a behavioral health provider, we are on the frontlines of the parity battle and welcome the opportunity to provide comments regarding strategies for increased enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA).
Rosecrance is a private not-for-profit organization offering behavioral health services for children, adolescents, adults, and families throughout the country. Rosecrance was founded in 1916 as an orphanage for boys and through the years, our work has evolved to meet the needs of children and families in our community and beyond.
Today, Rosecrance is one of the Midwest’s leading providers of behavioral health services and is nationally recognized for excellence in substance use disorder treatment. With more than 40 locations, Rosecrance offers comprehensive addiction and mental health services for adolescents and adults, including prevention, intervention, withdrawal management, residential and outpatient treatment, experiential therapies, dual-diagnosis care, and family education. We serve approximately 23,000 clients annually.
The Current Status of the Mental Health Parity and Addiction Equity Act
The Affordable Care Act and MHPAEA have already expanded access to treatment for millions of individuals suffering from substance use disorders (SUD) and mental health (MH) problems. Our organization has closely followed the progress of MHPAEA from its inception through its final rule-making process. We applaud the passage of MHPAEA and its progress at advancing parity for SUD and MH benefits; however, we still know that these benefits are treated differently than medical or surgical benefits resulting in less coverage and less treatment. Unfortunately, the full promise of MHPAEA has yet to be realized; however, the potential for true parity in the way SUD/MH benefits are treated can still be achieved through increased enforcement of MHPAEA.
Addiction and mental illness affects millions of Americans. Many of these individuals are in urgent need of treatment, yet they are unable to obtain care because insurance coverage for those treatment benefits is denied.
As a behavioral health provider, we deal with the many gaps and restrictions in insurance plan coverage for SUD/MH treatment on a daily basis, despite the fact that equitable coverage is required by parity. Even when insurance plans do cover SUD/MH treatment, they often impose obstacles to obtaining that care such as inappropriate denials based on lack of medical necessity; prior notification or authorization requirements; or even dangerous “fail first” policies. Access to care is further hindered by inadequate provider networks that do not include providers that offer the full range of covered services or specialize in adolescent care.
For example, we routinely experience the following practices that constitute parity violations if medical/surgical benefits are not treated in the same manner:
- Denial Rates – We routinely receive denials based on a purported lack of medical necessity, despite the fact that the treating clinician who saw the patient based his or her treatment recommendation on ASAM (American Society of Addiction Medicine) criteria. Although we do not have access to the data to prove it, we highly suspect the denial rates for SUD/MH benefits are significantly higher than comparable benefits on the medical or surgical side.
- Detoxification Services for Opiate Dependency – Many insurance companies refuse to cover detoxification for opiates, although they are covering detoxification for alcohol or other drugs. The reason we have been given is that opiate detox is not lethal and thus, residential detox is not medically necessary. Too often, the medically necessary standard is converted into a lethality standard, rather than its original intended purpose of ensuring the services provided were clinically appropriate. Denying coverage for opiate detox can be lethal, however, and a higher level of care is often required for treatment engagement and successful outcomes.
- Admission Preauthorization – We encounter a variety of pre-authorization practices that vary widely between insurance companies, but all require some version of pre-authorization for residential SUD/MH treatment. Some insurance companies also require pre-authorization for outpatient SUD/MH services. Furthermore, patients receive a financial penalty if the pre-admission authorization is not completed at least 24 hours prior to admission. These pre-authorization requirements are onerous and time-consuming and, even if pre-authorization has been obtained, this is often disputed after the claim has been submitted.
- Utilization Review – Payers require continuing stay reviews every few days or after a certain number of services for MH/SUD treatment. We devote significant time and resources to conducting utilization reviews. In some cases, we will request 14 days of treatment, but only 2 days of treatment will be approved. We believe that a comparison between SUD/MH and medical/surgical benefits would show that utilization review is conducted more frequently for SUD/MH treatment and that less treatment – at either a lower level of care or for a shorter duration – is approved for SUD/MH conditions.
- Fail-First Protocols – We have examples where a payer suggests trying a lower level of care first to see if that will be successful, despite our clinical recommendation for a higher level of care based on our personal interaction with the patient and our application of ASAM placement criteria.
- Chronic Disease Management Services – Insurers categorically deny coverage for recovery support services that are designed to help patients manage their conditions. As you know, addiction and mental health problems are chronic conditions that will always require some level of maintenance treatment, much in the same way as chronic medical conditions. Payers routinely deny recovery support services to manage chronic SUD/MH conditions, even though those same chronic disease and wellness services would be covered for the management of a chronic “medical” disease.
Enforcement Difficulties
Although we hear reports of some quantitative limitations still being imposed or categorical denials based on a type of service, the discrimination we see against SUD/MH benefits is generally more insidious. As a behavioral health provider, the disparate treatment of SUD/MH benefits is harder to prove now because the violation cannot necessarily be seen in one isolated case, but can only be seen in the patterns of how SUD/MH benefits are treated when compared to medical/surgical benefits. Any parity analysis requires a relative standard: the comparison between SUD/MH benefits and medical/surgical benefits
As a behavioral health provider, we only have access to one piece of the puzzle. We know how SUD/MH benefits are being treated, including denial rates, utilization review requirements, fail-first policies, and preauthorization requirements. We suspect that the obstacles on the SUD/MH are higher and more onerous than the medical/surgical side, but we need assistance from outside agencies and regulators who can access the data on both sides of the coin and compare SUD/MH benefits to medical/surgical benefits and determine if they are treated equally.
Another difficulty we encounter as a provider is knowing which agency has jurisdiction over any given plan. As you well know, enforcement of parity is delegated to both the federal and state governments and is split among different agencies at both levels, depending on the plan at issue. As a provider it is difficult for us to navigate the different enforcement agencies and different complaint procedures – we can only imagine the difficulty our clients face in attempting to file a complaint for a suspected parity violation. In addition to the complex complaint procedure, our patients and families report to us difficulty navigating the appeal procedures with their insurance plans. We often assist our clients with the first steps to try and secure coverage and will conduct the first and second levels of appeals. Once we have exhausted all our options as a provider, our patients are left to navigate the appeal processes on their own while they or a family member confronts a substance use disorder or mental health condition. Although we encourage our patients to pursue complaint or appeal procedures, it is not realistic that many of our patients or their families have the resources to do so.
Recommendations
While MHPAEA has already made great strides since its inception, we recommend the following to ensure MHPAEA accomplishes its goal of parity in the way SUD/MH treatments are treated:
- Consumer Education Campaign – At Rosecrance, we have noticed that most consumers are not aware of MHPAEA, the concept of Parity, or how it protects them. To be able to enforce their rights, advocate for themselves, and raise concerns, consumers need a baseline understanding of the concept of parity and that their SUD/MH benefits should not be treated differently than their medical benefits. Therefore, an extensive consumer education campaign should be developed and implemented so that consumers can voice their own concerns, can advocate for their own interests, and provide agencies with the information needed to better enforce MHPAEA. A public education campaign on parity rights for SUD/MH treatment should provide concrete examples of practices that raise red flags for potential violations and provide simple and clear steps for reporting suspected parity violations.
- Central Clearing House for Complaints – One of the most frequent issues that arise when we are assisting clients with potential Parity questions or complaints is identifying which State or Federal agency is responsible for oversight of a particular plan or managed care organization (MCO). The myriad areas of coverage and jurisdiction have caused confusion among our clients and the public. One approach we support would be to create one central agency that serves as the contact point for all Parity questions, complaints, and education. Patients, providers, family members, and other concerned individuals would have one location to conduct research into Parity, ask questions, identify potential violations, and file complaints. The centralized agency would be able to address both State and Federal Parity issues – either through internal processes or by referring the matter to the correct State or Federal agency responsible for oversight and enforcement of Parity with respect to the plan or MCO at issue. This “one stop shop” approach would minimize disruption to those people who are the most in need and who are undergoing one of the most traumatic events of their lives – dealing with a loved one that is desperately in need of life-saving mental health or substance use disorder treatment. We request that such an agency be designated or created as a joint venture between the States and the Federal government. This proposal would also create a tighter collaboration on Parity between State and Federal regulators and allow for the more efficient flow of information on Parity issues relating to MCOs or plans that operate in multiple jurisdictions, as well as identifying trends in Parity education and training based upon anonymized data that could be collected about questions and complaints from consumers, providers, and the public.
- Mandatory Disclosure – The federal government should require payers to provide comprehensive information that demonstrates plan compliance with Parity. The required disclosures should include not only plan documents that show the overall design of the plan, but also data from the actual operations of the plan, including denial rates based on claim type, utilization review frequency for different services, and pre-authorization requirements for different levels of treatment. It is of vital importance to consider both the plan policies as written and the actual practice patterns of the plan. State regulators should be encouraged to do the same for all commercial plans under their jurisdiction.
- Market Conduct Studies – Medicaid and private insurance claims data should be used to identify patterns of system-wide parity violations. Reimbursement patterns should be studied to identify practices that result in disproportionate denials of treatment for SUD/MH conditions. The data would also potentially reveal gaps in provider networks by tracking the disproportionate use of outof- network services for SUD/MH treatment. Federal and state governments should conduct – and be given the resources and guidance to do so – market conduct surveys to identify violations in the use of non-quantitative treatment limitations. We recommend utilizing market conduct studies to ensure that, even if a plan on its face complies with parity, that the method in which the plan is administered does not violate parity.
- Parity Compliance Officer – We request that payers be required to designate a parity compliance officer who has access to all plan data and documents so members, network providers, and regulators can readily access the information required to show parity compliance.
Rosecrance appreciates the opportunity to submit comments to the Listening Session. We applaud the important work that you are doing and we stand willing to serve as a resource to ensure there is meaningful access to quality care to treat all SUD/MH conditions. Thank you for your consideration.
Sincerely,
Kelly J. Epperson, J.D.
Vice President and General Counsel
kepperson@rosecrance.org | T 815.387.5698
