Source: https://www.hhs.gov/programs/topic-sites/mental-health-parity/achieving-parity/cures-act-parity-listening-session/comments/patients-and-advocates/legal-action-center/index.html
Timestamp: 2019-08-26 02:27:11
Document Index: 207549959

Matched Legal Cases: ['§ 54', '§ 2590', '§ 146', '§ 438', '§ 2590', '§ 146', '§ 54', '§ 2590', '§\n146', '§ 156', '§ 438', '§ 164', '§ 164', '§ 164', '§ 164', '§ 1320']

Legal Action Center | HHS.gov
Home > Programs > Topic Sites > Mental Health Parity > Achieving Parity > Cures Act Parity Listening Session > Comments > Patients & Advocates > Legal Action Center
Thank you for the opportunity to submit comments regarding the Department of Health and Human Services' (HHS) action plan for improved Federal and State coordination to enforce the Mental Health Parity and Addiction Equity Act (Parity Act). The Legal Action Center is a law and policy organization that works to end discrimination against individuals with histories of substance use disorders, HIVIAIDS and criminal histories through client representation and policy development. We submit these comments as a patient advocate and legal expert on the Parity Act. The Legal Action Center has published a guide to help consumers and providers enforce the Parity Act, Health Insurance for Addiction & Mental Health Care: A Guide to the Federal Parity Law, represents clients in Parity Act grievances against carriers and plan administrators, and engages actively in state enforcement of the Parity Act, in partnership with consumers and treatment providers, through state legislative, regulatory and Executive branch advocacy and policy development. In addition, the Legal Action Center co-chairs the Coalition of Whole Health, a coalition of national, state and local organizations advocating for the improved coverage for and access to mental health and substance use disorder prevention, treatment, rehabilitation and recovery services.
As highlighted below, the Legal Action Center urges HHS to adopt strategies and activities, plus a timeline, to fully implement the Parity Task Force recommendations set out in its October 2016 Final Report. In addition, we urge HHS to pursue several additional strategies that will significantly enhance Parity Act enforcement by shifting the enforcement paradigm from an individual complaint-driven model to a prospective compliance review model. This strategy will implement federal regulatory requirements that bar health plans from offering plans that do not comply with the Parity Act (26 C.P.R.§ 54.9812-1(h); 29 C.P.R.§ 2590.712(h); and 45 C.P.R.§ 146.136(h)) and incorporate a prospective compliance disclosure standard comparable to that required under the Medicaid parity regulations. 42 C.P.R.§ 438.920(b).
Benefit and prescription drug coverage and medical management standards that fully align with the Parity Act
Full disclosure ofthe Parity Act's non-discrimination standards and tools
(compliance officer contact information and document links) that would provide consumers immediate access to plan documents that are needed to assess compliance and pursue complaints.
Help regulatory agencies enhance the substance use disorder and mental health provider community's capacity to identify potential Parity Act violations and advocate for plan compliance in network adequacy and rate setting standards.
The Departments of Health and Human Services, Labor and Treasury have issued extensive regulatory and sub-regulatory guidance to facilitate enforcement of the Parity Act. The Parity Task Force enhanced federal and state enforcement capacity in October 2016 by funding state regulatory enforcement efforts, providing technical assistance through State Parity Academies, developing a Consumer Web Portal that directs consumers with complaints to appropriate regulatory bodies, and issuing a disclosure guide that reinforces the obligation of ERISA plans to disclose plan documents related to the design and application of non-quantitative treatment limitations (NQTL). Enforcement will be further bolstered by prompt implementation of all remaining Task Force recommendations, particularly those requiring:
Federal agency disclosure of parity investigations, results and violations, optimally in real­time rather than annually;
Office of Personnel Management review ofNQTLs applicable to substance use disorder benefits in Federal Employee Health Benefits Program (FEHBP) plans and implementation of corrective actions;
The Mental Health & Substance Use Disorder Parity Task Force, Final Report, 23-28 (Oct. 2016). We urge HHS to fully pursue each of these initiatives in its action plan to ensure that all individuals have access to equitable substance use and mental health benefits.
Even with the adoption of the above strategies, we remain concerned that compliance and enforcement efforts at both the state and federal level have focused primarily on strategies that are of limited utility in their ability to root out parity violations.1 Discriminatory insurance coverage of mental health and substance use disorder benefits persists because the traditional regulatory approach to compliance review- plan document review, utilization review agent certification, and consumer complaint investigations- will not uncover the vast majority of Parity Act violations. Regulators are not given information that is required for a complete analysis of plan compliance; consumers do not have the information, capacity or resources to navigate the inefficient appeals process, particularly in the midst of a health crisis; and treatment providers face significant challenges responding to the worst opioid epidemic in history, leaving little time to challenge the exclusion of medically necessary benefits,1 excessive authorization requirements,3 denials of authorization or exceedingly short authorization periods.
The adoption of a prospective parity compliance review requirement - implemented through a Parity Act Transparency and Compliance Report tool- would address a significant gap in current enforcement efforts. The recent report, Parity Tracking Project: Making Parity A Reality,4 prepared by the Legal Action Center, National Center on Addiction and Substance Abuse, Treatment Research Institute and The Partnership for Drug-Free Kids (submitted as an attachment) identifies the long list of plan design features that regulators cannot evaluate for parity compliance during form review, simply because key information is not provided in plan documents. (Table 1: Summary ofFindings at 23-24). For example:
Disparities in the coverage and management of medications for substance use disorders suggest that regulators do not review plan formularies/prescription drug lists to determine whether the scope of coverage, tier places and utiljzation management are compliant.
Documents provides no information about NQTLs, other than prior authorization requirements for specific levels of care. Even with regard to prior authorization, the plan's standards for imposing and applying this NQTL is not referenced in plan documents and cannot be determined from form review.
Carriers that rely on behavioral health organizations (BHOs) to manage substance use and mental health benefits may defer to the BHO's utilization management standards, but it is not evident that the BHO's documents are collected or evaluated by regulators to compare standards for medical, substance use and mental health benefits.
(Making Parity a Reality at 7-8, 32-35, 37-51).
The mandatory submission of a Parity Act Transparency and Compliance Report tool to support the carrier or plan sponsor's request for plan approval is essential to prevent the sale of discriminatory health plans. While some State regulators conduct market conduct surveys and audit coverage retrospectively through data reporting, these tools allow for the review of only a small slice of the carrier's plan rather than the full scope of plan design features as written and in operation. 29 C.F.R. § 2590.712(c)(4); 45 C.F.R. § 146.136(c)(4). Most important, the time involved in conducting a thorough investigation of carrier conduct undermines the value of market conduct examinations as a tool to ensure real-time access to non-discriminatory coverage.5
Pre-market compliance reports would place responsibility of demonstrating compliance on the entities that have a legal obligation to offer parity compliant health plans and possess the documentation to demonstrate plan compliance. It would also relieve consumers of the nearly impossible burden of identifying Parity Act violations and asserting their right to health care in the midst of a health crisis. The American Medical Association supports this strategy to improve parity compliance. https://wire.ama-assn.org/delivering-care/key-opioid-progress-make-insurer-comply-treatment-access
Barring the sale of plans that do not satisfy this requirement is fully consistent with existing regulatory standards (26 C.F.R. § 54.9812-l(h); 29 C.F.R. § 2590.712(h); and 45 C.F.R. §
146.136(h); and 45 C.F.R. § 156.115(a)(3)) and would create an economic incentive for carriers to address violations. This standard also aligns with CMS standards that require Medicaid managed care organizations and States to demonstrate that their Medicaid programs comply with the Parity Act. 42 C.F.R. § 438.920(b) Other federal consumer health protection standards, such as the health privacy standards under the Health Insurance Protection and Portability Act (HIPAA), rely on an enforcement framework that places the onus on covered entities (including insurers and health care providers) to comply with the law rather than relying on consumer complaints.6
Descriptions of substance use disorder benefits do not confirm coverage of all critical benefits, as outlined by the American Society of Addiction Medicine's (ASAM) criteria to treat addiction.
The Parity Act's non-discrimination protections are not explained in plan documents and information about filing a complaint does not specifically reference how to file a parity complaint.
(Making Parity a Reality at 9-10, 32-34, 54-56).
States, such as New York, have begun to use model contracts to help carriers demonstrate compliance with the range of state and federal insurance laws. An enhanced model contract is a useful tool to address limitations in the description ofbenefit coverage and notification of Parity Act protections. We recommend that federal and state regulators develop examples of model contract language that are written at an appropriate reading level and contain the following information:
The consumer's right to obtain services from in-network providers and options for obtaining services if the carrier does not have an in-network provider.
Identification ofthe Parity Act's non-discrimination standards, availability of plan documents to assess possible violations, and the process for appealing a denial of services or reimbursement that implicates the Parity Act.
IV. Enhance the Provider Community's Capacity to Identify Potential Parity Act Violations and Advocate for Plan Compliance in Network Adequacy and Rate Setting Standards.
Providers of substance use and mental health services have an important stake and role in the enforcement of the Parity Act. First, providers must use the Parity Act's protections to obtain admission to networks and secure equitable reimbursement rates. Plan design features regulated under the Parity Act, including reimbursement rates, network admission, credentialing standards, and network adequacy standards, determine whether providers offering a full continuum of services will be included in carrier networks. Second, providers are uniquely positioned to support their patients in accessing parity compliant care. They are often the front-line responders when a plan denies care authorization, excludes benefit coverage or imposes medical necessity standards that are inconsistent with evidence-based practices. Consumer access to care is clearly dependent upon a provider community that is knowledgeable about the Parity Act protections and equipped to assert those standards.
To enhance provider capacity, the federal government should follow its model for enhancing state regulatory capacity: make funding and technical assistance available to mental health and substance use disorder providers to improve their substantive knowledge of the Parity Act; provide technical assistance on insurance contracting and credentialing; and assist with the development of strategies that enable providers to file complaints effectively and efficiently. While a provider/consumer complaint process is not a substitute for a prospective compliance reporting requirement, this tool will remain an important part of enforcement efforts. Thank you for considering our views and the opportunity to offer brief remarks at the Listening Session.
1 For example, the Parity Task Force reported that federal enforcement efforts had focused on investigating complaints rather than conducting random audits and recommended increased funding to expand audit capacity. (Task Force Report at 27). It also noted that CMS had not conducted parity compliance reviews of plans subject to essential health benefit requirements, resulting in some state benchmark benefit plans.
2 For example, over the past two years, I have represented many clients whose commercial and self-insured plans exclude coverage for methadone maintenance treatment, while covering medication assisted treatment for medical conditions. One national carrier, although aware of the clear Parity Act violation, claims that only the plan sponsor of self-insured plans can modify the benefit exclusion and has not addressed this violation across all plans for which it serves as the third-party administrator. This benefit exclusion should never be permissible under the Parity Act, yet regulators do not identify it.
3 The same national carrier imposes notification and authorization requirements for virtually all substance use disorder benefits other than standard outpatient treatment, even though the DOL's Warning Signs­ Plan or Policy Non-Quantitative Treatment Limitations (NQTLs) the Require Additional Analysis to Determine Mental Health Parity Compliance flags this carrier's precise practice: pre-notification for all mental health and substance use disorder inpatient services, intensive outpatient program treatment, and extended outpatient treatment visits beyond 45-50 minutes. Warning Signs at 2 available at https://store.samhsa.gov/shin/content//SMA16-4983/SMA16-4983.pdf.
4 The study sought to evaluate whether the two groups on the front-lines of Parity Act enforcement­ regulators and consumers -could identify Parity Act violations through the standard regulatory review process known as form review (for regulators) and, for consumers, readily identify benefit and prescription drug coverage, out-of-pocket costs and any restrictions on accessing substance use disorder care and identity plan design features that raise "red flags" for violations through publicly available documents. The study examined seven large and small group employer plans offered in New York and Maryland in the 2015 or 2016 plan years. The study methodology and findings are fully set out in the report.
5 By way of example, the Maryland Insurance Administration has conducted two market conduct examinations since late 2014 with each taking over eighteen (18) months to complete. Both examinations probed a limited set of plan design features. (Market Conduct Surveys on file with the author). The first examination resulted in the filing of five orders in November 2015 that identified violations related to network adequacy, including the total absence of methadone treatment programs in the network of the State's predominant carrier. The second examination identified additional network adequacy violations based on the lack of outpatient in-network opioid treatment programs in 6 out of 24 jurisdictions and outpatient in-network programs that treat bi-polar disorder in 11 of24 jurisdictions. Maryland Insurance Administration to Honorable Thomas McLain Middleton (June 30, 2017) (letter on file with author). Significant gaps in provider access to methadone treatment in the face of the opioid crisis must be addressed immediately, not delayed by years of data collection and review.
6 Under HIPAA, covered entities must demonstrate compliance via comprehensive written policies and procedures. 45 C.F.R. § 164.530(i)-(j). The covered entity must explain its obligations to consumers in a privacy notice, which must also contain a statement of the individual's rights under HIPAA and a process for registering complaints. 45 C.F.R. § 164.520(b)(l(iv)- (vi). Each covered entity must designate a Privacy Officer, who is responsible for overseeing HIPAA policies and compliance, receiving complaints and responding to requests about the covered entity's privacy practices. 45 C.F.R. § 164.530(a). Further, a covered entity must have procedures in place for filing such complaints and must document all complaints received, and their disposition, if any. 45 C.F.R. § 164.503(d). Finally, the act also imposes monetary penalties for violations, which promotes compliance. 42 U.S.C. §§ 1320d-5 and 1320d-6.