To: Mental Health and Substance Use Disorder Parity Task Force

August 25, 2016

To: Mental Health and Substance Use Disorder Parity Task Force

The Association for Ambulatory Behavioral Healthcare (AABH) appreciates the opportunity to respond to your request for feedback concerning the coverage and implementation of the ACA (Affordable Care Act) and MHPAEA (Mental Health Parity and Addiction Equity Act.) AABH is composed of hundreds of partial hospitalization and intensive outpatient programs nationwide.

We support the regulations, guidance, and other related efforts by the administration that is central to the success of the Administration’s major substance use disorder (SUD) and mental health (MH) initiatives. The federal MH/SUD parity law and the ACA present the greatest opportunities our nation has ever had to dramatically improve access to care for these diseases that afflict tens of millions of Americans.

Eight years after the advent of parity legislation, we see that partial hospitalization (PHP) and intensive outpatient programs (IOP) function as the bridge between inpatient and outpatient services within the behavioral health continuum. Even though these programs are part of most behavioral health insurance plans, the full promise of the federal MH/SUD parity law can only be realized through the inclusion of these essential intermediate benefits in all plans.

Upon analysis, we find that there is significant variation in the degree to which the parity law is being followed throughout the individual states. The AABH encourages full enforcement of these laws at the federal and state levels. Intermediate behavioral health services that include partial hospitalization and intensive outpatient treatment are evidence-based and critical to reduce the duration and frequency of inpatient episodes of care. People in need of MH and SUD care can benefit greatly and overcome significant access to care problems when these services are included in their healthcare plans. Even when these MH and SUD services and medications are available and covered by health plans, it can be difficult for individuals to access the appropriate type and duration of care. Coverage and access to care problems continue to be more of a challenge for people with MH and SUD care needs than for people with other chronic health conditions. To make the requirements of the federal MH/SUD parity law meaningful, we urge the federal government, through the Department of Health and Human Services, Labor and Treasury, to directly and actively enforce the law.

The following is a summary of our concerns and recommendations for the Task Force, followed by more detailed comments and recommendations for your consideration:

1. The federal government should issue additional specific guidance to State regulators and plans on how to implement the federal parity law, identify parity violations, and enforce the law in both public and private insurance.

2. The federal government should insure that intermediate behavioral healthcare benefits such as partial hospitalization and intensive outpatient benefits are included adequately in both public and private healthcare plans.

3. Federal and State regulators should robustly enforce the requirements of the federal MH/SUD parity law prospectively during plan approval and retrospectively through complaint investigations.

We have seen significant gaps and restrictions in insurance plan coverage of substance use disorders and mental health care, even when such coverage is required by federal parity law. Consumers are paying for what they believe are comprehensive benefits.

Studies by the Coalition for Whole Health, American Society for Addiction Medicine, National Alliance on Mental Illness (NAMI), National Center on Addiction and Substance Abuse, Legal Action Center, and state-based organizations have documented many concerns. These include deficiencies in states’ benchmark plans that result in the failure of many essential health benefit (EHB) based insurance plans to cover services that include intensive out-patient and partial hospitalization services. Even when insurance plans do cover services, they can impose burdensome obstacles to obtaining that care. These burdens include denials based on inconsistent medical necessity criteria, cumbersome prior authorizations and re-authorizations, designated step therapy requirements, and other procedural barriers to appropriate care. Access to care is further hindered by inadequate provider networks that do not include providers that offer the full range of covered intermediate behavioral health services. At times, additional guidelines issued from other federal departments actually contribute to a reduction in access and availability of services rather than a realization of parity.

When partial hospitalization and intensive outpatient services are available, consumer responses to care are consistently positive. Virtually all programs conduct patient satisfaction surveys and many participate in AABH’s “Patient Perception of Care Survey” which is benchmarked nationally. Consumers have identified access to care challenges within the behavioral health continuum. In 2015, NAMI conducted a “Coverage of Care Survey” that identified a number of challenges in accessing MH care. According to one respondent, “I don't even try to use the mental health benefits provided by my insurance company. It requires pre-authorization by one of their providers. My psychiatrist isn't in any network. I have been going to her for over 20 years. She is part of the reason I'm still on this earth. I spend roughly $175 per month to see her - and it's worth it. I would spend less money on food, if I had to, rather than stop seeing her.” Another consumer shared, “The majority of the mental health professionals in my area do not participate in any insurance plans. The in-network providers do not have the same level of quality care. Thus, I must use my out of network benefits to get any insurance coverage for the psychiatrists, therapists, and outpatient treatment centers. My insurance plan has a $8000 deductible for out of network benefits. We have depleted all our savings and incurred much debt to get the quality mental health care we need.” These personal experiences, which are shared by many across the country, signal Parity Act violations.

Several additional examples of parity compliance problems demonstrate that we are missing the opportunity to effectively address our nation’s serious heroin/opioid epidemic and increase in suicides due to significant treatment gaps for both MH and SUD care. Many insurance plans:

• Do not cover all three of the FDA-approved addiction medications – buprenorphine, methadone, and injectable naltrexone, even as they cover the medication for pain and other chronic disease treatments. It is thus not surprising that a study just published in Health Affairs found that insurance financing has not increased for substance use disorder treatment.

• Do not cover or restrict access to intermediate MH, SUD and eating disorder treatment, even when treating professionals determine a needed length of stay based on clinical criteria, despite covering comparable levels of care for other chronic health conditions.

• Provide rational and evidence-based strategies and standards to encourage prompt access to cancer or heart disease medications and services but provide significant barriers to lifesaving MH and SUD medications and services.

A small sample of news media articles from around the country report complaints from families who suffered personal tragedies or financial disaster when they were forced to pay out-of-pocket when insurance companies refused to reimburse for needed care. In addition, a large number of people with untreated serious mental illness or SUD are in county and local jails because they lack adequate health insurance coverage and access to MH and SUD care. On any given day, up to three-quarters of the jail population suffers from these illnesses. Robust enforcement of the federal MH/SUD parity law will help ensure that people will receive the services and medications they need to avoid or reduce serious exacerbation of symptoms, suicide, incarceration, and disability.

Following are our detailed recommendations:

1. The federal government should develop additional specific guidance to State regulators and plans on how to implement the federal MH/SUD parity law, identify parity violations, and enforce the law in both public and private insurance.

The final MHPAEA regulations have created a strong legal framework, but more detailed federal guidance to State regulators, including insurance departments and Medicaid agencies, is needed. This guidance should use concrete examples to clarify what the federal MH/SUD parity law requires and provide additional detail about best practices that States can implement as they monitor and enforce federal law. The federal government should also provide additional clarity and communication about state regulator roles and responsibilities related to enforcement, including clearer guidance about how corrective action should be taken. This should include:

• Guidance on the use of Medicaid and private insurance claims data, which is available to identify trends that will uncover system-wide violations of the federal parity law. The data would reveal reimbursement patterns from which regulators can readily identify utilization management strategies (notification, authorization, and fail first requirements) that result in disproportionate denials of care for MH and SUD care. The data would also reveal gaps in provider networks by tracking members’ disproportionate use of out-of-network services for MH and SUD services.

• Specific templates for oversight of the scope of benefit coverage and non-quantitative treatment limitations to make parity requirements as clear as possible for plans and state regulators.

• We recommend that HHS and CCIIO issue guidance to States on how to simplify and clarify the process for consumer complaints regarding parity violations.

We appreciate the explicit inclusion of MH and SUD service providers in network adequacy requirements for Medicaid and the commercial market and look forward to continued work by the federal government to ensure these protections are meaningful. We urge the federal agencies to develop specific guidance to State regulators on how to monitor and determine whether these network adequacy requirements of the federal MH/SUD parity law are being met. Intensive outpatient and partial hospitalization treatment is critical to reduce and avert inpatient hospitalization care. Adequate availability and access to provider networks is essential to meet the expectations of parity legislation.

2. The federal government should insure that intermediate behavioral health benefits such as partial hospitalization and intensive outpatient treatment is adequately included in both public and private benefit plans.

Behavioral healthcare providers continue to hear from consumers and family members around the country that it continues to be difficult to obtain complete coverage information, including information about benefits, medications covered, medical necessity criteria, and the network MH and SUD providers. Intensive outpatient and partial hospitalization treatment is critical in providing immediate access and treatment for acute behavioral healthcare that does do require inpatient hospitalization. Without the availability and access to intermediate behavioral healthcare, expensive and unnecessary emergency department care is often the only available option for individuals in acute emotional crisis.

2015 AABH benchmarking data show that 52% of admissions avert inpatient treatment. Access to immediate medications and treatment and next day treatment often follows each referral. These services are highly regulated, fully evidenced based, and benchmarked nationally by AABH, where outcomes are tracked by individual programs. In their June 2016 study, the National Center on Addiction and Substance Abuse emphasized “the importance of different levels of care to provide different treatment types and intensities of services.” They have determined that one-third of the 2017 EHB-benchmark plans contain possible parity violations related to the coverage of intermediate behavioral healthcare services. Parity violations exist when plans impose different cost sharing requirements or treatment limitations for intermediate behavioral health services as compared to intermediate medical services. They emphasize that “covered benefits should not be subject to overly restrictive treatment limitations or utilization management practices, high copayments, or other limitations that restrict access to care. Allowing for access to a range of levels of care, including inpatient, outpatient, and intermediate care improves patient outcomes by matching patients to the appropriate level of care for their needs and can reduce costs to the health plan in the long term.”

3. Federal and State regulators should robustly enforce the requirements of the federal MH/SUD parity law prospectively during plan approval and retrospectively through complaint investigations.

The federal government should require Exchange plans to provide comprehensive information that demonstrates plan compliance with the federal MH/SUD parity law as part of the plan certification process. State insurance departments should require the same for all other commercial plans. Plan design is not generally a part of plan review. State insurance departments should assess compliance that discloses all plan design features.

• Intermediate behavioral health programs effectively and efficiently impact the overall quality of care for those who are in emotional crisis. However, we continue to see coverage gaps despite federal guidance that partial hospitalization and intensive outpatient treatment must be covered at parity with intermediate levels of care for other illnesses. If home healthcare is included as an outpatient benefit, then partial hospitalization and intensive outpatient treatment should also be included as an outpatient benefit. In addition, some plans identify intensive outpatient treatment and partial hospitalization as “inpatient” services. This classification as an inpatient service should not impose greater cost-sharing requirements on consumers that may result in decreased access to care and an increase in those who suffer in silence.

Thank you for the tremendous leadership this Administration has displayed in enacting and implementing strong inclusion of mental health and substance use disorder services at parity in national health care reform. AABH strongly supports the inclusion of intermediate behavioral health benefits to enhance and secure the psychiatric continuum of care. We look forward to continuing to work with you to enhance the emotional and physical health of all Americans.

Thomas Miller, MSW

AABH President

Association for Ambulatory Behavioral Healthcare