FEDERAL – Mental Health Parity and Addiction Equity Act of 2008

• The 2008 Mental Health Parity and Addiction Equity Act already requires insurers and corporate-backed health plans to provide access and payment structures for mental health care services on par with other medical services.
• In practice, that is often not the case, with less than half of U.S. adults with mental illness able to access care in 2020, while nearly 70% of children cannot receive treatment, according to studies cited by the administration.
  • Under the new rules, federal officials are clarifying that autism, intellectual and neurodevelopmental disorders and all other conditions listed in the mental, behavioral and neurodevelopmental disorders chapter of the current International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders must be included under the definition of “mental health benefits” for plans and coverage.
  • Biden admin to require mental health coverage parity  – The White House says health insurers are not complying with 2008 law in a move that’s likely to draw legal challenges from the industry Politico September 22024 
    • Our webpage on Autism
  • Final Rule to strengthen Parity Law 9/9/2024 Reuters 
  • Fact Sheet: Final Rules under the Mental Health Parity and Addiction Equity Act (MHPAEA) 
• Fact Sheets & FAQs On Mental Health Parity 2008
  • Regulations & Guidance
  • 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