Mental Health Parity
Parity is the Law of the Land
After many years of hard work parity is now the law of the land at both the federal and state level in Wisconsin. But in order for people living with mental illnesses and addiction disorders to receive the full benefits of the laws, the laws must be implemented as envisioned by Congress and the Wisconsin State Legislature. This requires that consumers, family members, advocates and providers all understand what the laws require and what to do if you think they are not being implemented correctly.
The federal Wellstone-Domenici act was passed by Congress on October 3, 2008 and went into effect with new health plans starting October 3, 2009. Wellstone-Domenici applies to all health plans for employer groups of more than 50 employees; including those that self-insure (self-insured private companies cannot be regulated by state law).
Wellstone-Domenici required the responsible federal agencies to develop regulations to define many of the terms used in the law and provide more specific guidance on how the law is to be implemented. The interim final rule was published in the federal register on Feb. 2, 2010.
The regulations are very important because they were written in such as way as to limit the ability of health plans to treat mental health and substance use disoders more restrictively in a variety ways; not just based on copayments or visit limits. For instance the regulations require the non-quantitative treatment limits be no more restrictive for MH/SA disorders than for other conditions. This would apply to how standards for medical necessity are applied and how inpatient treatment stays are reviewed and approved. The rules also make clear that separate but equal deductibles for MH/SA services are not acceptable.
On April 30, 2010 Governor Jim Doyle signed 2009 WI Act 218, the Wisconsin Parity Act. This bill fills in part of the coverage gap left by Wellstone-Domenici. Specifically it:
- Requires that health plans for employer groups of 10 or more provide MH/SA benefits at parity, using language following federal law.
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For employers covered by the Act (those who are commercially insured, not those who are self-insured) it requires that MH/SA benefits be provided. Federal law allows plans to choose not to provide MH/SA coverage but requires parity if these benefits are provided.
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Incorporates the federal cost increase exemption language.
Because the federal and state laws have somewhat different requirements and somewhat different scope
this grid may be helpful in understanding which laws effect you depending upon your employer group size and type of health plan.
In order to ensure that people are receiving the benefits to which they are entitled it is important that insured individuals examine their statement of benefits in the member handbook of their health plan policy. This document, developed with regard to the federal law, can assist in knowing what to look for: Assessment Tool
Because this tool was developed for use with the federal law you need to ask one additional question: are MH/SA services covered. If your employer purchases commercial insurance than it must include coverage for MH/SA services.
Appeals/Complaints: If individuals believe their plan does not comply with the requirements of the law they should first contact their health plan. There may be additional information that is not contained in the statement of benefits or other factors impacting the coverage. If it still does not appear that the plan is in compliance ask whether there is an appeal process to bring this to the plan's attention. Sample appeal letter
Medical Necessity: A specific type of problem likely to be encountered in making parity real relates to medical necessity determinations. While plans cannot establish more restrictive limits on MH/SA services they can still utilize medical necessity as one factor in determining whether they will authorize services and at what level. And while the regulations clarify that medical necessity cannot be applied in a more restrictive manner for MH/SA services than for other conditions the fact that this is a somewhat more subjective area may make it ripe for abuse. The regulations also seem to suggest that plans must use accepted criteria for medical necessity, but they do not fully explain how this is to be determined. Sample medical necessity letter
One thing the rule is clear about is that plans must make their medical necessity criteria available to planholders and that they must provide planholders with information about denials due to not meeting medical necessity guidelines. Individuals can use the templates above to request information from their health plans about medical necessity.
The Office of the Commissioner of Insurance has responsibility for ensuring that health plans comply with both the federal and state laws. You may file a complaint with OCI if you believe you are not receiving the benefits to which you are entitled. Click here to file a complaint online.
You may also call the complaints and information toll-free number at 1-800-236-8517 (within Wisconsin) or 1-608-266-0103 (outside of Wisconsin) or send an e-mail message to ocicomplaints@wisconsin.gov.
According to their website, this is what will happen after a complaint is filed:
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A copy of your complaint will be sent to the company or agent with a request to respond directly to you and to advise the OCI of the action taken. You should hear from the company or agent in about 25 days from the date you send your complaint.
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When the information is received from the company or agent, OCI will review the file to determine what action can be taken. You will be notified of the determination.
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If the OCI is unable to obtain the resolution you desired, you may consider contacting a private attorney for advice. If your complaint involved a claim dispute, you may want to contact your county's small claims court.
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OCI also manages an independent review process. This process may be particular helpful in cases where service is being denied due to medical necessity. According to OCI:
The independent review process provides an opportunity to have medical professionals who have no connection to your health plan review your dispute. You choose the IRO from a list of review organizations certified by OCI. The IRO assigns your dispute to a clinical peer reviewer who is an expert in the treatment of your medical condition. The clinical peer reviewer is generally a board-certified physician or other appropriate medical professional. The IRO has the authority to determine whether the treatment should be covered by your health plan. Click here for more information including how to initiate this process.
