Insurance Update

Summary of Department of Managed Health Care's (DMHC) Consumer Provider Plan Agency (CPPA) Meeting 

(February 27, 2017) 
Sara Kashing, JD
Staff Attorney

Every few months, a CAMFT Staff Attorney participates in meetings of the Consumer Provider Plan Agency (“CPPA”) Mental Health Work Group which is hosted by the Department of Managed Health Care (Department). The Department oversees

most health care service plans (including Kaiser Permanente), health maintenance organizations (“HMOs”) incorporated in California, as well as California Blue Cross and Blue Shield participating provider organizations (“PPOs”).

The purpose of the quarterly CPPA meetings, held in Sacramento, is to bring mental health consumer and provider advocates together with representatives of the managed care plans that are regulated by the DMHC to discuss issues related to the delivery of mental health
care in California.

Mental Health Parity Compliance Update
Elizabeth Spring, Senior Attorney with the Office of Plan Licensing, provided the group with an update on the Department’s parity enforcement project. The Department is in the process of completing the on-site Mental Health Parity and Addiction Equity Act
compliance surveys of 25 commercial plans. As the Department completes the on-site reviews, it will draft preliminary reports related to those reviews. The preliminary drafts of the reviews are confidential and go only to the plans. The plans then have 45
days to review the Department’s findings and come up with a Corrective Action Plan. The Department will then use the plans’ responses to finalize its reports which must be made available to the public within 180 days of the Department’s completion of the
on-site surveys. The Department anticipates completing the last of the 25 on-site reviews by the end of June.

CAMFT asked whether the Department had made any determinations about how it is going to tackle the parity reimbursement issue.

Ms. Spring reported that the Substance Abuse and Mental Health Services Administration, a unit of the Centers for Medicare & Medicaid Services, selected 20 states to participate in a federal mental health parity project. Ms. Spring and an attorney from the Department
of Insurance will participate in the group and will receive input from other States and the Department of Labor about how best to assess parity in regard to provider reimbursement. This project is just getting underway, but Ms. Spring will provide the group with an update
at the next CPPA meeting.

CAMFT also asked Ms. Spring to address whether health plans requiring pre-authorization for mental health treatment, but not for medical/surgical treatments raises concerns about parity compliance. Ms. Spring stated this is one of the issues
being reviewed as part of the Department’s parity enforcement project. She indicated they investigated any pre-authorization discrepancies during the first phase of the project and that the Department did find occasional discrepancies. In those cases, the
Department issued pointed questions to the plans and is requesting further information during the on-site survey process so it can review the plans’ relevant policies and procedures even more closely.

Department of Managed Care Update
The Department recently hired five new Deputy Directors, including Chief Medical Officer, Kaiser Kim. Mr. Kim will be in charge of assisting the Department’s Help Center with clinical issues.

County Mental Health Plan and Medi-Cal Managed Care Plan Coordination
Linnea Koopmans, a Senior Policy Analyst, at the County Behavioral Health Director’s Association, gave a brief presentation on some of the issues the counties are experiencing from a care coordination standpoint. The counties and the Medi-Cal Managed Care
Plans are having difficulty deciding which entity is responsible for treating particular clients when there is disagreement about the level of care that a patient requires. The Department of Health Care Services requires counties and plans to have Memoranda of
Understanding (“MOUs”) which outline their responsibilities. In recognition of this problem and to better ensure continuity of care for consumers, the Department is offering further instructions through All Plan Letters and Information Notices about what the MOUs
must address.

Help Center Update
The Department’s Help Center received a total of 330 mental health case complaints between September and December of 2016. Of those 330 complaints, 225 of them resulted in Independent Medical Reviews. Only 84 of the plan’s original determinations
were overturned. (Note: To file a complaint, visit www.dmhc.ca.gov.)

Discussion about Health Plan Care Guidelines
Randall Hagar, Director of Government Relations for the California Psychiatric Association, presented the memo he and CAMFT’s Deputy Executive Director, Cathy Atkins, drafted outlining concerns regarding the complex guidelines providers are expected
to follow and to encourage discussion about whether there are ways to make provider guidelines uniform across the plans.

Representatives from Anthem Blue Shield (Rob Friedman) and Optum (Mimi Maguire)indicated that plans initially adopted their guidelines from Interqual and Milmen’s Clinical Guidelines. However, over the years, the cost of using these standard guidelines
caused plans to revert developing their own. Both Anthem and Optum have national assessment committees that are responsible for developing national guidelines. Therefore, Mr. Friedman and Ms. Maguire suggested any changes to the guidelines would have to be
made at a national level.

CAMFT and CPA asked that the DMHC and the CPPA work group work together to create a single repository for the plans’ guidelines.

Sara Jasper, JD, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.