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January 10, 2018 Sacramento
Managing Director of the Legal Department, Ann Tran-Lien, and Staff Attorney, Sara Jasper met with members of the Department of Managed Health Care, including Mary Watanabe, Deputy Director, Health Policy and Stakeholder Relations, Gil Duran, Health Policy and Stakeholder Engagement Officer and James Willis, Senior Counsel to discuss the following issues:
Results of the Department’s Parity Compliance Surveys Congress enacted the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008. MHPAEA requires health care service plans that provide mental health and substance use disorder (MH/SUD) benefits to provide those benefits at the same level as the Plan’s medical/surgical benefits. The MHPAEA does not require a plan to offer MH/SUD benefits, but if the plan does so, it must offer the benefits on par with the medical/surgical benefits it covers.
Most plan benefits are subject to financial requirements, such as copays, coinsurance, and deductibles, and to treatment limitations, such as needing to obtain plan approval before you receive treatment. Under MHPAEA, health plans must ensure that financial requirements and treatment limitations that apply to MH/SUD benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.
The federal government authorized states to enforce plan compliance with MHPAEA. The Department provided an update on the Department’s Parity Compliance Project. During Phase 1 of the Department’s compliance surveys, 25 health plans submitted information about their parity compliance policies. Phase 1 of the project was completed in April of 2016. During Phase 2 of the compliance surveys, the Department conducted on-site reviews of the 25 commercial plans. The on-site reviews concluded in fall of 2017. Three preliminary reports have been issued for Health Net, Cigna and Molina. The information can be found on the DMHC’s website under the health plan dashboard (http://www.dmhc.ca.gov/HealthPlanDashboard.aspx). The reports can be accessed through the Medical Surveys hyperlink or by the Licensing and Reporting tab on the Home Page, then the Health Plan Compliance Medical Survey hyperlink http://www.dmhc.ca.gov/LicensingReporting/HealthPlanComplianceMedicalSurvey/ViewMedicalSurveyReports.aspx. More reports will be issued by the end of January.
CAMFT has been eagerly awaiting the results of the compliance surveys, especially in regard to the health plans’ handling of non-routine mental health treatment requests. Department staff had indicated the results would be available on the DMHC’s website at the end of 2017. However, given its other priorities, the Department indicated the public release of a summary of all the survey results would likely be available by the end of this year. The Department will likely issue a summary of aggregate findings of all the survey results some time in 2019.
CAMFT expressed concerns that plans are either denying claims billed with 90837, requiring pre-authorizations for 90837, or sending out threatening letters when providers bill 90837. It is our understanding that plans are categorizing these longer sessions as “non-routine services.” CAMFT inquired as to whether the Department was able to review these practices as a part of the parity compliance survey project. The Department indicated that although it did find issues with plans’ preauthorization requirements, there were no findings in regard to this issue. CAMFT will review the survey findings when the Department makes this information available.
In the interim, members who have encountered these situations with plans and have concerns about potential harm to patients may contact the toll-free Provider Complaint Line at 1-877-525-1295. Patients may also file a complaint directly with the Consumer Help Center at dmhc.ca.gov or by calling 1-888-466-2219. Providers can assist patients with the consumer complaint process by working with the patient to complete the Authorized Assistant form that is a part of the DMHC’s Independent Medical Review/Complaint form.
Provider Reimbursement Parity CAMFT has continuously urged the Department to review and provide guidance to insurers and stakeholders on how the Department plans to enforce provider reimbursement as a form of nonquantitative treatment limitation. During the last CPPA meeting on May 12, 2017, the Department indicated it has been participating in SAMHSA’s Parity Academy and that the Department was using that forum to gather information from other states about how to ensure parity with regard to provider reimbursement. New York, New Hampshire and Pennsylvania, looked at this issue after having enacted all-payer claims database laws. In these states, useful databases have been created and are accessible by regulatory agencies, insurers, and members of the public. The states were able to use information gleaned from the databases to figure out, in commercial coverage markets, whether mental health providers are being paid in parity with other providers of similar classifications. The challenge in California is that no laws currently exist to require the development of all-payer databases.
At the meeting, CAMFT asked Department to provide an update on the Department’s efforts on enforcing this issue here in California, and expressed the importance of this matter to providers and patients. Given that there is much disagreement among stakeholders about the value of all-payer databases, the Department does not expect to see this type of legislation in CA and is going to continue looking to other states and CMS for guidance on how to tackle this issue. CAMFT will continue to monitor this issue and advocate for an analysis and eventual enforcement of the issue in California.
Future of the CPPA Meetings The Department has not held a CPPA meeting since May of last year. CAMFT expressed its desire to see these meetings continue because they are important opportunities to provide the Department with information about what is happening on the provider/consumer level as well as opportunities to receive information and feedback from the health plans’ on provider issues.
CAMFT will advocate to keep these meetings moving forward, as it is one of the few opportunities that plans and providers meet face to face on neutral ground to discuss issues of mutual interest, as foster common ground.