Mental Health as an essential benefit under ACA Health Care Reform 
Parity Laws – Mental Health must be equal to Medical Benefits

#California Mental Health Insurance Parity

Summary:

AB 88 CA Insurance Code §§10144.5.  Health and Safety Code§1374.72  requrires that severe mental illness for children be covered and also prohibits health plans from basing medical necessity denials on whether the admission for mental health services was voluntary or involuntary, WIC 5150 hold  ^{CA Legislator *} or on the method of transportation of the patient to the health facility.

AB 88 also requires Insurance Companies  that offer mental health services (Individual & Families * Medi-Cal * Employer Groups)  to have information on their website that will assist enrollees in accessing mental health services.  ^{SB 1553  §1368.015, §1367.015Health & Safety Code Blue Cross / Anthem Mental Health Procedures}

SB 221   Return Visit Guarantees 

SB 221   requires that Mental health and substance abuse patients be offered return appointments no more than 10 days after a previous session, unless their provider OKs less frequent visits. ^{CA HealthLine}  *  ^{CA Health Line 11.24.2021} *

Severe Mental Illness Coverage
AB 88 – Insurance Code §10144.5

(a) Every policy of disability (health) insurance that covers hospital, medical, or surgical expenses in this state* … shall provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child, … under the same terms and conditions applied to other medical conditions,

(b) These benefits shall include the following:

(1) Outpatient services.

(2) Inpatient hospital services.

(3) Partial hospital services.

(4) Prescription drugs, if the policy or contract includes     coverage for prescription drugs.

How to obtain, get or find these benefits?

(c) The terms and conditions applied to the benefits required by this section that shall be applied equally to all benefits under the disability (Health, Medical)  insurance policy shall include, but not be limited to, the following:

(1) Maximum lifetime benefits.

(2) Co-payments and coinsurance.

(3) Individual and family deductibles.

 (d) For the purposes of this section, “severe mental illnesses” shall include [these diagnosis]:

(1) Schizophrenia  schizophrenia.com/ *** WebMD

(2) Schizoaffective disorder. ***  WedMD

(3) Bipolar disorder (manic-depressive illness). bipolar.com/***  WebMD

(4) Major depressive disorders. ***  WebMD

(5) Panic disorder. ***  WebMD

(6) Obsessive-compulsive disorder.***  WebMD

(7) Pervasive developmental disorder WebMD  or autism. *** Web MD

(8) Anorexia nervosa. *** WebMD

(9) Bulimia nervosa.  ***   WebMD

(e) For the purposes of this section, a child suffering from, “serious emotional disturbances of a child” shall be defined as a child who

(1) has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders,  other than a primary substance use disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected developmental norms, and …

Mental Health Parity at a Crossroads

California Law Aims to Strengthen Access to Mental Health Services

SB 855 2020 
#Substance Abuse Treatment

SB 855 requires insurance companies to expand the definition of Mental Health to include Substance abuse and cover as any other illness.   Learn More — Bill Summary

(g) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.  ^{Autism 7.1.2012 SB 946  §10144.5.}

Plans must  cover out-of-network services based on billed charges (rather than a discounted allowed amount or negotiated price) immediately if the plan was not able to provide in-network services in a timely manner based geographic access and timeliness requirements. ^{CA Health Line} *

Links & Resources

• Blue Shield Summary & FAQ’s *
• CA Insurance Commissioner letter to All Health Insurance Companies to comply with SB 855 to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.
• magellan provider focus.com/what-you-need-to-know-about-senate-bill-855
• Analysis of California Senate Bill 855 Health Coverage: Mental Health or Substance Abuse Disorders 104 pages report to State Legislature
• aacap.org/Medical_Necessity_Criteria
• Treatment Guidelines: Substance Use Disorders
• PRACTICE GUIDELINE FOR THE Treatment of Patients With Substance Use Disorders Psychiatry Online . org  276 pages
• Magellan’s Adopted Clinical Practice Guidelines For the Assessment and Treatment of Patients With Substance Use Disorders
• Fact Sheet SB 855 5 pages Senator Scott Wiener

FEDERAL – Mental Health Parity and Addiction Equity Act of 2008

• Fact Sheets & FAQs
• Regulations & Guidance
• United loses in court on behavioral health coverage rules Modern Health Care 3.5.2019
• Wikipedia 
• Code of Federal Regulations §146.136   Parity in mental health and substance use disorder benefits.

Mental Health Bill of Rights

• Pending? telehealth ‘Bill of Rights’ for mental health care services

 

The Mental Health Parity Act of 1996 (MHPA)

 

MHPA is a federal law that may prevent your group health plan from placing annual or lifetime dollar limits on mental health benefits that are lower – less favorable – than annual or lifetime dollar limits for medical and surgical benefits offered under the plan.  Learn more on Wikipedia Mental Health Parity Act 1996

The act removes separate treatment limitations for mental health and chemical dependency benefits (including number of visits, days of coverage, and annual dollar limits) and requires cost sharing for these services to be equal to or less than the cost sharing for other health care services. ^{(Federal Mental  Health Parity Act of 2007 NAMI More on Mental Health Parity NAMI) Public Law 110–343 wikipedia.org/110-343}

MHPA applies to most group health plans with more than 50 workers. MHPA does NOT apply to group health plans sponsored by employers with fewer than 51 workers. MHPA also does NOT apply to health insurance coverage in the individual market.

MHPA is a federal law that requires that annual or lifetime dollar limits on mental health benefits provided by a group health plan be no lower than the annual or lifetime dollar limits for medical and surgical benefits offered by that plan. MHPA applies to employers with more than 50 employees. For up to date information on the applicability of the Mental Health Parity Act, contact the EBSA regional office nearest you.

• Statute1185 A
• Regulations
• Fact Sheet
• Publications

The MHPA does not prohibit group health plans from:

Covering mental health services within network only, even though the plan will  pay for out of network services for

• medical/surgical benefits (although with  higher out-of-pocket cost to the subscriber);
• Increasing co-payments or limiting the number of visits for mental health  benefits;
• Imposing limits on the number of covered visits, even if the plan does not impose  similar visit limits for medical and surgical benefits; and
• Having different cost-sharing arrangements, such as higher coinsurance payments for mental health benefits, as compared to medical and surgical benefits
  • HOWEVER, check out the rules under ACA/Obamacare & AB  88

.A visit limit coupled with a usual, customary, and reasonable (UCR) charge is not  the equivalent of an annual or lifetime dollar limit. As a result, it is not a  violation of the MHPA requirements.  Payments made by the plan on the basis of  UCR charges will vary from one case to the next.

What is not permitted is a limit  on the number of visits, together with a fixed dollar limit per visit, for example,  60 visits annually at $50 per visit (totaling $3,000), unless the medical-surgical  coverage is the same.cms.hhs.gov

Maximum #a190 Medicare Psychiatric Inpatient Days?

 

• If one is mentally #ill, has Medicare and Medi Cal, is constantly in and out of inpatient care, will Medi Cal pay if Medicare doesn’t as the person maxed out his inpatient days and used up the lifetime limit?
  • • Yes, Medicare pays or doesn’t pay and then Medi Cal is the secondary payer.  ^{§ 1300.67.13. Coordination of Benefits (“COB”)}.
    • References & Links
    • Our webpages on:
    • What is covered under Medicare Parts A & B
    • Appeals & Grievances
    • Dual Coverage
      • Which Pays first Medi Cal or other coverage?
      • Medicare 
        • Medicare #DualCoverage
          # 02179  
        •  
        • most health care costs are covered if you qualify for both Medicare and Medicaid.  Medicaid never pays first for services Medicare covers. It only pays after Medicare has paid Page 11
        • Choose Medi Cal HMO
    • SSI, SSDI & Automatic Medicare Coverage

  Medicare Benefit Period – CA Health Care Advocates

  Medicare & You Publication 10050  Page # 121

  Benefit period

  The way that Original Medicare measures your use of hospital and skilled nursing facility services. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a skilled nursing facility) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

  Mental health care (inpatient)  Medicare.Gov  Medicare & You page 27

  However, if you’re in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.

  • Try Medi Cal for additional days

• LA Care EOC Evidence of Coverage and Member Handbook

  Coordination of Benefits (COB): The process of determining which insurance coverage (Medi-Cal, Medicare, commercial insurance or other) has primary treatment and payment responsibilities for members with more than one type of health insurance coverage.

  The LA Care EOC page 49  states:

  Other Medi-Cal programs and services

  Other services you can get through Fee-For-Service (FFS) Medi-Cal or other Medi-Cal programs

  Sometimes L.A. Care does not cover services, but you can still get them through FFS Medi-Cal or other Medi-Cal programs. This section lists these services. To learn more, call L.A. Care Member Services at 1-888-839-9909 (TTY/TDD 711).

• Medi Cal coverage – County Mental Health

• Specialty mental health services

  Some mental health services are provided by county mental health plans instead of L.A. Care. These include specialty mental health services (SMHS) for Medi-Cal members who meet medical necessity rules. SMHS may include these outpatient, residential and inpatient services:

  • Inpatient services:
  ° Acute psychiatric inpatient hospital services
  ° Psychiatric inpatient hospital professional services
  ° Psychiatric health facility services

  To learn more about specialty mental health services the county mental health plan provides, you can call your county mental health plan.

• To find all counties’ toll-free telephone numbers online, visit dhcs.ca.govMHPContact List

  • • • Medi-Cal Specialty Mental Health Services
        • ​​​​​​CalAIM 1115 Demonstration & 1915(b) Waiver
      • Medi Cal and Social Service Contacts for Assistance
      • dmh.lacounty.gov
      • Evidence of Coverage D SNP – Page 77
      • CBO.gov THE INPATIENT PSYCHIATRIC HOSPITAL BENEFIT UNDER MEDICARE  July 1993
      • Medi Cal Inpatient Mental Health Services Program
      • chcf.org/Medi Cal Explained Behavioral Health.pdf 
      • ‘Go on Medi-Cal to get that’: Why Californians with mental illness are dropping private insurance to get taxpayer-funded treatment
      • Advocates Guide to Medi Cal – Mental Health
      • Cal. Code Regs. Tit. 9, § 1820.205 – Medical Necessity Criteria for Reimbursement of Psychiatric Inpatient Hospital Services
      • MHSUDS INFORMATION NOTICE NO.: 19-026