Mental Health Parity: Equal Access for Children and Youth in California
This content delves into the importance of mental health parity for children and youth in California, covering topics such as mental health facts, co-occurring conditions, impact of delayed intervention, and the disparities in insurance coverage. It emphasizes the need to address mental health issues early to prevent adverse outcomes like school dropout and involvement in the juvenile justice system.
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Presentation Transcript
Mental Health Parity: Assuring Equal Access to Treatment for Children and Youth in California Nancy Shea Mental Health Advocacy Services, Inc. August 16, 2017
What This Webinar Will Cover Why this matters What is mental health parity Overview of mental health parity under state and federal laws How to challenge decisions and policies of insurance companies 2
Some Mental Health Facts 20% of youth ages 13 18 live with a mental health condition Suicide is the 3rd leading cause of death in youth ages 10 24. 3
Student Related Depression-Related Feelings by Grade Level (2011 2013) 7th Graders 25.3% 9th Graders 30.7% 11th Graders 32.5% 4
Co-Occurring Medical-Psychological Conditions Children with chronic illness and disability are at 3 times greater risk for psychiatric problems Children with chronic illness and no disability are at 2 times greater risk for psychiatric problems 5
Impact 50% of all lifetime cases of mental illness begin by age 14 and 75% by age 24 The average delay between onset of symptoms and intervention is 8 10 years 6
Why does this matter? Approximately 50% of students age 14 and older with a mental illness drop out of high school. 70% of youth in state and local juvenile justice systems have a mental illness. 7
Why focus on mental health parity? Historically, insurance companies have provided unequal coverage between physical health care and mental health care. A form of discrimination 8
What is parity? Examples of what parity is not: Copays Inpatient days Prior authorization 9
Parity means equivalent, equal, or comparable treatment Mental Health parity laws: Created in response to unequal coverage and discrimination Require health insurance plans to provide equivalent, equal, or comparable coverage for physical and mental health (including substance abuse disorders) 10
Federal Mental Health Parity Laws The Mental Health Parity Act of 1996 The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 The Patient Protection and Affordable Care Act of 2010 11
California Mental Health Parity Law The California Mental Health Parity Act of 1999 12
CA Mental Health Parity Act Applies to: Types of plans: Health plans that are regulated by the state (individual and small group plans; fully insured large group plans) 13
CA Mental Health Parity Act Does not apply to: Types of plans: self-funded plans (many large employers and unions offer these type of plans) Medicare Medi-Cal Veterans Administration health plans 14
CA Mental Health Parity Act Applies to: Groups of people Adults who have a severe mental illness Children who have severe emotional disturbances (SED) 15
CA Mental Health Parity Act Covered conditions (for adults) Major depression Bipolar disorder Schizophrenia Schizoaffective disorder 16
CA Mental Health Parity Act Covered conditions (for adults) Anorexia Bulemia Obsessive-compulsive disorder 17
CA Mental Health Parity Act Covered conditions (for adults) Autism or pervasive developmental disorder Panic disorder 18
CA Mental Health Parity Act Severe emotional disturbances (for children): Has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and Meets the criteria in Welfare & Institutions Code section 5600.3(a)(2) 19
CA Mental Health Parity Act WIC Section 5600.3(a)(2) Substantial impairment in at least 2 of the following areas: Self-care School functioning Family relationships Ability to function in the community and 20
CA Mental Health Parity Act WIC Section 5600.3(a)(2) One of the following occurs: At risk of removal from the home or has been removed Impairment has been present for more than 6 months or is likely to continue for more than one year with treatment 21
CA Mental Health Parity Act WIC Section 5600.3(a)(2) Displays one of the following: psychosis, risk of suicide or risk of violence Identified as eligible for special education as emotionally disturbed 22
CA Mental Health Parity Act Coverage must be equal in terms of: Maximum lifetime benefits Copayments Deductibles 23
CA Mental Health Parity Act Coverage includes: Outpatient services Inpatient services Partial hospital services Prescription drugs (caveat) 24
CA Mental Health Parity Act Coverage mandate: All medically necessary treatment for the listed severe mental illnesses or severe emotional disturbance must be covered under the same terms applied to physical illnesses. 25
CA Mental Health Parity Act Two important court cases: Harlick v Blue Shield of California, 686 F.3d 699 (2012) Rea v Blue Shield of California, 266, Cal. App. 4th 1209 (2014) 26
Federal Laws Affordable Care Act (ACA) Created 10 essential health benefits Expanded existing federal parity laws to more health plans Expanded appeal rights to more health plans 27
Federal Laws Affordable Care Act (ACA) Essential Health Benefits include: Mental health and substance use disorder services 28
Federal Laws Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Apply to following plans: Employer-based plans (with more than 50 employees) Qualified Health Plans (plans offered on the Exchange, i.e., Covered California) All individual plans 29
Federal Laws Apply to (cont): Most small group plans Medi-Cal Managed Care Plans Medi-Cal Benchmark and Benchmark- Equivalent Plans (ACA Medi-Cal expansion) 30
Federal Laws Do not apply to following plans: Grandfathered small group plans (plans from before March 23, 2010) Medicare Part A and B Medi-Cal 31
Federal Laws Do not apply (cont): Veterans Administration health plans Tricare 32
Federal Laws Six categories of benefits Inpatient; in-network Inpatient; out-of-network Outpatient; in-network Outpatient; out-of-network Emergency care Prescription drugs 33
Federal Laws Quantitative treatment limits: Copays Deductibles How often one gets care Number of visits Days of treatment 34
Federal Laws Non-quantitative treatment limits: Formulary design Utilization review Step therapy Geographic proximity Timely access to care 35
Appeals Process Internal review External review Consumer complaint 36
California Regulatory Agencies California Department of Managed Health Care (DMHC) regulates health care service plans DMHC Help Center 1-888-466-2219 www.HealthHelp.ca.gov 37
California Regulatory Agencies California Department of Insurance (DOI) regulates health insurance plans. California Department of Insurance 1-800-927-4357 http://www.insurance.ca.gov/01- consumers/101-help/ 38
Internal Appeals Insurance plan denies, changes, or delays a service or treatment because It is not medically necessary It is for experimental or investigational treatment It involves emergency services already received 39
Internal Appeals Must be notified sufficiently in advance to allow time for an appeal Must be given opportunity to appeal the termination or reduction before it takes effect. 40
Internal Appeals Fairly simple process to file with health plan (usually form and instructions are attached to denial notice) Insurance company reviews the claim Must be resolved within 30 days 41
External Review Also known as an Independent Medical Review (IMR) Independent doctor reviews the case Have 6 months to file an appeal with the DMHC or the DOI 42
Urgent Health Situations Waiting jeopardizes life or the ability to regain maximum function Internal and external review can be requested at the same time Final decision must be reached within 4 business days 43
Consumer Complaint General complaint about a health plan, provider, or medical group, including: Delays in getting an appointment, referral or authorization Claims, billing and co-payment issues Terminations or cancellations of coverage 44
Consumer Complaint Access to translation and interpretation services Finding and in-network doctor, hospital or specialist 45
Consumer Complaint Complaints about a doctor or plan Doctor or hospital is no longer with your health plan (Continuity of care) 46
Timely Access to Care Non-Urgent mental health appointment (non-physician): 10 business days 47
Tips for Appeals and Complaints Keep asking and appealing denials frequently get overturned at every stage of the process Keep your appeals factual and brief Meet all deadlines 48
Tips for Appeals and Complaints Keep detailed records Ask for help from your health providers Get reason for denial in writing Keep bugging the insurance company 49
Lesson Learned Don t Take No For An Answer 50
