State Leadership Conference

Given the number of participants at a workshop on parity, “there may be some parity anxiety going on,” said Doug Walter, JD, counsel for legislative and regulatory affairs in APA’s Practice Directorate.

Walter chaired a session on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act at the 2011 State Leadership Conference, held March 12-15 in Washington, D.C.

The federal law, which applies to group health plans covering 51 or more employees, says that financial requirements and treatment limits applied to mental health and substance use benefits should be no more restrictive than those applied to medical and surgical benefits.

The government issued a rule giving detailed compliance requirements last year. “Regulators went a bit further than the law’s statutory requirements,” said Walter, explaining that the regulations demand parity in nonquantitative areas as well. Although what that means is still “mushy,” he said, examples include differences in medical management and provider network participation. The standards are likely to be better defined as questionable insurance company practices are challenged, he added.

How have employers reacted to parity’s passage? According to Ron Bachman, president and chief executive officer of Healthcare Visions Inc., the impact has been minimal. Despite some grumbling and confusion, “the vast majority implemented parity without a hitch,” he said.

Cost concerns turned out to be minimal, said Bachman, explaining that insurers simply folded costs into routine increases. Employers with mental health plans “carved out” from medical plans faced some challenges getting those systems to communicate and develop common deductibles and cost-sharing, but most did so successfully. And despite fears that parity would cause employers to drop mental health benefits, a 2010 Kaiser Family Foundation survey found that just 1.6 percent of affected employers — mostly those that didn’t offer much mental health coverage to begin with — did so.

Why did employers accept parity so readily? “The scientific evidence,” said Bachman. “You made your case — those of you who are out there in the community sharing information with legislators and the press and doing all those great things you’ve been doing to help support this.” Employers, he said, understand that stress, depression and other behavioral health problems affect their bottom lines and that treating such physical conditions as diabetes and heart disease without addressing behavioral health issues doesn’t make sense.

What about companies that aren’t complying? “The main thing we hear are questions about management of the benefit,” said Alan Nessman, JD, senior special counsel for Legal and Regulatory affairs in APA’s Practice Directorate. “What we’ve seen is that once the parity law took away companies’ ability to limit care to say 20 sessions a year, some companies appeared to panic.” Fearing that patients would indulge in excessive therapy, they developed several strategies for limiting patients’ access. These include authorization requirements and telephone reviews ostensibly designed to determine medical necessity.

A checklist Nessman developed can help psychologists figure out whether a company’s management techniques violate parity. One critical question is whether the practice imposes a barrier to patients’ access to mental health care. Other basic questions include the following: Is the plan exempt from the law? Is its management of mental health benefits more intrusive than what happens on the medical side? How does the company justify differences? A more detailed checklist is available at Practice Central.

Terence J. Koller, PhD, executive director of the Illinois Psychological Association (IPA), described a successful effort to ensure Blue Cross Blue Shield’s compliance. The company announced that when the law went into effect on Jan. 1, patients would have to get pre-authorization to access behavioral health services. The pre-authorization was supposed to consist of an easy, online check-in that would automatically result in an OK for 10 sessions.

To IPA, it seemed like a clear parity violation, because this was not required for most medical services. Plus, psychologists and patients alike were either unaware of or confused about the policy change. As January approached, said Koller, the company was totally unprepared to implement the new system. That meant that the easy online pre-authorization would be replaced by jammed phones lines — something that could seriously interrupt patient care.

IPA members bombarded legislators, the state insurance director and Blue Cross Blue Shield with complaints. The result? On Dec. 31, the day before the change was to go into effect, the company rescinded the decision.

The fight’s not over, however. The company said it would continue to require pre-authorization for psychological and neuropsychological testing.

“Having our members — and our health-care reimbursement committee — stay on top of this made a huge difference,” said Koller.

Rebecca A. Clay is a writer in Washington, D.C.