Understanding the Mental Health Parity Law An employer s guide to the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act

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Understanding the Mental Health Parity Law

An employer ’s guide to the Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008


| Understanding the Mental health Parity law—A b r I E F o v E r v I E W o F T H E l AW 2

whAt does the lAw require?

The Mental Health Parity law considers three aspects of health care coverage:

Financial requirements or what employers think of as cost-sharing provisions

Treatment limitations, such as the maximum number of services covered

Network limitations, such as what is or is not covered out of network in a network-based benefit plan In each of these areas, employers cannot impose any requirements that are more restrictive than the “predominant” requirement or limitation that applies to “substantially all” medical/surgical benefits.

which group heAlth plAns Are

Affected by the lAw?

Your employee health care benefits are affected by the Mental Health Parity law if you have more than

50 employees. As a federal mandate, the law affects groups that are fully insured as well as those that are self-funded. The law also affects group retiree coverage, including Medicare complementary benefits as well as Medicare Advantage plans.

A b r i e f o v e r v i e w o f t h e l Aw


when is the lAw effective?

The Mental Health Parity law goes into effect one year after the date it was enacted, October 3, 2008. Your compliance date depends on how your plan is set up:

If you have a calendar year plan, you need to comply by January 1, 2010.

If you have a contract year plan, you need to comply by your first renewal that occurs on or after

November 2009.

If your health care benefits are provided as part of a collective bargaining agreement, you need to comply by January 1, 2010, or upon the expiration of your last bargaining agreement that was ratified before october 3, 2008, whichever date is later.

(Any bargaining agreement extensions agreed to after october 3, 2008 do not delay your compliance date.)

does the lAw require groups to

provide mentAl heAlth or

substAnce Abuse benefits?

No, the law does not mandate these benefits. What it does require: If the group health care benefits include coverage for mental health or substance abuse services, there needs to be parity between this coverage and the coverage for medical/surgical benefits.

NoTE: various state mandates regarding coverage for mental health and/or substance abuse care apply to fully insured groups.


| Understanding the Mental health Parity law—A b r I E F o v E r v I E W o F T H E l AW 4

how does this lAw relAte to other

mAndAtes for mentAl heAlth or

substAnce Abuse coverAge?

The Mental Health Parity and Addiction Equity Act of 2008 expands the requirements of the 1996 federal Mental Health Parity Act. The new law:

Includes the provisions of the 1996 law. Group health care benefits cannot include annual or aggregate lifetime dollar limits for mental health benefits that are separate from and less than the limits that apply for medical/surgical benefits.

Expands the “parity” requirements to prohibit more restrictive:

Financial – or cost-sharing – requirements Treatment limitations

Network limitations

Applies to substance abuse benefits as well as mental health benefits

If your benefits coverage is fully insured — as opposed to self-funded — you also need to be aware that many states have mandates that affect mental health and/or substance abuse coverage. For example, fully-insured health care plans offered by Pennsylvania-based employers are subject to:

Act 106 of 1989 – benefits for Alcohol Abuse and

Dependency. This law mandates certain levels of coverage for inpatient detoxification and

rehabilitation and outpatient substance abuse services.

Act 150 of 1998. This law mandates certain levels of

inpatient and outpatient coverage for nine specific “serious mental illnesses,” such as schizophrenia and other disorders. It applies to insured groups with more than 50 employees.

Act 62 of 2008. This law, which affects insured

groups with more than 50 employees, mandates coverage for autism spectrum disorders, beginning with July 2009 renewals.


stArt by Asking yourself

these questions:

Is our organization affected by the law? If so, when do we need to comply? Are our benefit designs in compliance? If not, what changes need to be made? And what are our options?

Your Highmark sales representative is prepared to work with you to help you answer these questions and to discuss your options for benefit designs that comply with the Mental Health Parity law and meet your and your employees’ needs.

w h e r e d o yo u s tA r t ?

Although the Mental Health Parity law will not affect your group health care coverage

immediately, you need to start looking at your organization and your benefit plan design

now so that you are prepared to make the right decisions with your next group renewal.

Terms You Need to Know:

Throughout this guide you’ll see a number of terms from the Mental Health Parity and Addiction Equity Act of 2008 with which you need to be familiar. Here are definitions of these terms to keep in mind as you read through this guide and look more closely at your own health care benefit design.

Financial requirements – the law uses this term to refer to the various

types of employee cost-sharing features typically found in health care coverage. Financial requirements include deductibles, copayments, coinsurance and out-of-pocket limits.

Treatment limitations – the law uses this term to refer to limits typically

placed on various types of health care services in terms of the scope of that coverage or duration of treatment. For example, a benefit design may limit how frequently certain types of treatment may be received, the number of visits, number of inpatient days of coverage or other similar limits. These are considered treatment limitations.

Network parity – this term comes into play for network-based health care

coverage. If, for example, a group health care plan provides coverage for out-of-network medical/surgical benefits, the Mental Health Parity law requires the plan to provide similar coverage for out-of-network mental health/substance abuse benefits. And any cost-sharing requirements for out-of-network services need to be at the same level for both

medical/surgical and mental health/substance abuse benefits.

Predominant – most common or frequent. The law refers to “predominant”

financial requirements and treatment limitations for medical/surgical benefits and requires similar or richer financial requirements or treatment limitations for mental health/substance abuse benefits.

Substantially all – when determining the “predominant”financial


| Understanding the Mental health Parity law—A r E Yo U r b E N E F I T S I N C o M P l I A N C E ? 6

First, identify the “predominant” medical/surgical cost-sharing features and treatment limitations of your benefit design. Look at any:

Copayments Coinsurance Deductible(s)

limits on benefits payable on an annual or lifetime basis

The limit on out-of-pocket amounts your members are responsible for

limits on inpatient days limits on outpatient visits

Differences in coverage for network and out-of-network coverage

Then, determine if there are differences between these cost-sharing features and limitations between the coverage for medical/surgical services and the coverage for mental health/substance abuse services.

If there are no differences or your mental

health/substance abuse benefits are richer than your medical/surgical benefits, your benefit design is in compliance.

If there are differences, your benefits will need to be adjusted to remove or change any cost-sharing or other limitations on mental health/substance abuse benefits that do not apply to substantially all of your

medical/surgical benefits to bring you into compliance by the required date for your coverage.

mAking benefits equAl –

whAt you need to consider

Many employers question what the effect will be of removing stricter cost-sharing or treatment limitations from their mental health/substance abuse benefits and implementing a benefit design with the same cost-sharing and treatment limitations for all services. Although changes in utilization will vary by group and may not be completely predictable, the mental health/substance abuse treatment limitations that are most common in Highmark benefit designs were selected to provide a reasonable level of coverage for members. For example, many plans provide 30 days of inpatient mental health coverage, and — even when this limit is removed — it is unlikely that many members would use more inpatient care than this. raising the level of mental health/substance abuse benefits, however, does present some risk.

A r e yo u r b e n e f i t s i n c o m p l i A n c e ?


Employers may also choose to reduce their

medical/surgical benefits to bring them in line with the cost-sharing features and treatment limitations that currently apply for their mental health/substance abuse benefits. but, using the same example of inpatient days, many employers may be reluctant to limit their

employees to 30 days of inpatient coverage for medical/surgical care.

The examples below provide typical benefit provisions and the changes that could be made to bring them into compliance with the Mental Health Parity law.

This example removes the limits on mental

health/substance abuse coverage so that these benefits are equal to the coverage for medical/surgical services. Highlighted areas indicate where changes are needed.

This example is only one way to bring the benefits into compliance. Other options include changing the medical/surgical benefits so that they include the same limitations as the mental health/substance abuse benefits or moving to a completely different benefit design that includes the same level of cost-sharing and treatment limitations for all health care services.

benefit provision network out-of-network network out-of-network

MEDICAL OFFICE VISIT $20 copay 80% after deductible $20 copay 80% after deductible

MENTAL HEALTH OUTPATIENT $20 copay; Limit: 20 visits 50% after deductible; Limit: 10 visits $20 copay; Unlimited visits 80% after deductible; Unlimited visits

HOSPITAL INPATIENT 100% 80% after deductible 100% 80% after deductible

MENTAL HEALTH INPATIENT 100%; Limit: 30 days 80% after deductible; Limit: 10 days 100%; Unlimited visits 80% after deductible; Unlimited visits SUBSTANCE ABUSE OUTPATIENT $20 copay; Limit: 60 visits per benefit period; 120 visits per lifetime

80% after deductible; Limit: 60 visits

combined with network

$20 copay; Unlimited visits

80% after deductible; Unlimited visits


| Understanding the Mental health Parity law—o N E S o lU T I o N : A C o I N S U r A N C E - b A S E D P l A N D E S I G N


Complying with the Mental Health Parity law can be a good opportunity to take a new look at your existing health care benefit design to determine if it meets your long-term cost management needs. One

alternative to consider is a coinsurance-based benefit design, that is, a design in which employees pay a percentage of the cost of all eligible services.

Implementing coinsurance for all of your health care coverage offers you a number of advantages:

It is a cost-management strategy that can offset the removal of the cost-sharing features for mental health/substance abuse services. And, by applying a single cost-sharing feature — a set percentage — to all benefits, you’ll know that your mental health/substance abuse benefits are in parity with your medical/surgical benefits.

It’s an easy benefit design for employees to understand. Many of today’s most popular cost-management features have made health care plans more complex than ever before. Members need to keep track of various copayment amounts for office visits, brand-name and generic drugs, emergency room care and other services. They may have deductibles that apply to certain medical services but not others. Coinsurance simplifies all of that because members are responsible for a fixed percentage — for example, 20 percent — of the cost of every eligible service.

It gives members a greater incentive to become more involved in health care decisions. When members are responsible for a specific percentage of the cost of their care, they have a vested interest in spending their health care dollars wisely. So they are more likely to want to know the cost of care before they receive medical services. They may even be more willing to take the right steps to leading a healthy lifestyle. In short, they are transformed from health care users to educated health care consumers, which is the key to long-term cost management.

o n e s o l u t i o n :

A c o i n s u r A n c e - b A s e d p l A n d e s i g n

Online tools help consumers

“shop” wisely

Highmark recognizes the need to help our members become smarter health care consumers. This is even more important when members are paying a percentage of the cost of their care. That’s why our Web site now includes a wide range of easy-to-use online tools. Members can:

Get the price of a specific procedure, such as an office visit, blood test or


Learn more about medications and their cost before they have a

prescription filled.

Find out the most likely treatment for a newly diagnosed condition and

how much services such as surgery, therapy or other ongoing care are likely to cost.

Get other helpful information, such as tips on how to talk with your


w h At e l s e d o e s t h e l Aw r e q u i r e ?

The Mental Health Parity law includes two

requirements regarding disclosure of information. Health plans must disclose:

The criteria for medical necessity determinations with respect to mental health/substance abuse benefits to participants, beneficiaries or contracting providers if they request this information

The reason for any denial of reimbursement or payment for mental health/substance abuse benefits to any participant requesting this information

Can you apply for an exemption from the law?

Employers are permitted to file for an exemption from the Mental Health Parity law if they meet certain criteria. Here’s the process a group needs to follow:

The employer group must comply with all requirements of the law for the first plan year. After six months, the group needs to look at the total cost of its benefits. If that cost has increased by more than two percent, the group can apply for an

exemption from the law’s requirements for the following benefit plan year. The cost increase must be attributable to the application of the parity requirements and certified by a qualified actuary. The documentation of the cost increase must be retained for six years.

note: An exemption applies for

only one benefit plan year.


| Understanding the Mental health Parity law—S H o U l D Yo U C o N S I D E r D r o P P I N G M E N TA l H E A lT H b E N E F I T S ? 1 0

s e l f - f u n d e d g r o u p s :

s h o u l d yo u c o n s i d e r d r o p p i n g m e n tA l

h e A lt h b e n e f i t s ?

If you self-insure your health care benefits and are considering eliminating coverage for mental health and substance abuse services, there are a number of things you need to be aware of. The Mental Health Parity Act does permit employers to define these benefits and, in doing so, to control the scope and cost of this coverage.

Before you make your decision, however, you need to recognize that not providing mental health/substance abuse coverage can be costly — in terms

of “indirect” costs, including:

• Increased utilization of medical services • lower productivity

• lost work days

• Increased on-the-job injuries • Decreased work quality • Higher employee turnover

one reason mental health and substance abuse issues can be so costly is because the onset of mental illness, unlike most chronic medical conditions, is often at a younger age. In fact, mental disorders are the leading cause of disability in the U.S. and Canada for people between the ages of 15 and 44.*

because depression can be particularly costly to

employers, efforts to treat it can deliver real, measurable rewards. one study shows that efforts to identify and treat depression in the workplace significantly improves employee health and productivity, likely leading to

lower overall costs for the employer. In this study, which monitored two groups of employees who suffered from depression, those who received phone support from a care manager and additional assistance of their choice were 40 percent more likely to recover from their

depression, 70 percent more likely to stay employed and worked an average of two more hours a week than employees in the group that did not receive additional care.**

It has also been shown that conditions related to mental health and substance abuse can actually increase medical costs. For example, one analysis indicates that 41 percent of people with a psychiatric disorder smoke.†That’s twice

the overall smoking rate. It’s well known that smoking leads to other physical illnesses, which, in turn, increase the utilization of medical care. Compromised immune systems and diseases that can result from alcohol or drug abuse are additional examples of how untreated mental health or substance abuse problems can lead to health problems requiring medical care. Patients with chronic medical conditions — such as congestive heart failure — can become depressed, making them less likely to follow treatment plans, which, in turn, can lead to the need for more costly medical care.


w h At w i l l h i g h m A r k d o t o h e l p

m A n A g e c o s t s ?

Highmark has long recognized the need to take a proactive approach to the management of mental health and substance abuse care. In 2005, we created an integrated medical and behavioral health utilization and case

management program. our multi-disciplinary clinical staff of behavioral health specialists shares the same clinical information system used by our medical care and case management team. As a result, we benefit from an integrated clinical member record that provides a total picture of the member’s mental and physical health. This dramatically increases our ability to focus on the needs of high-risk members and subsequently impact care costs. All inpatient admissions for mental health or substance abuse care are preauthorized, using McKesson InterQual medical necessity criteria for mental health care and criteria from the American Society of Addiction Medicine (ASAM) for substance abuse services. If medical necessity is questionable, psychiatric physicians are available to consult with the care managers. Continued stay reviews are conducted frequently during the stay, and all members receive an outreach phone call from the continued

stay care manager within one business day after their discharge. This call is designed to ensure that all appropriate follow-up care is arranged and accessible to the member and that the member is evaluated for inclusion in one of the behavioral health case management programs.

With the implementation of the Mental Health Parity law, our comprehensive approach to behavioral health management will take on an even greater significance. Highmark has already begun to look at ways we can expand our efforts to ensure that members receive the right care in the right setting at the right time. our Depression Management program, for example, represents an opportunity to address this growing problem and its effect on health care costs and workplace productivity. A flexible program that was designed to be easy to adapt and to provide reportable results, this program now has a 20 percent enrollment rate and has generated positive feedback from employers and members. our plans for the Depression Management program include expanded data mining and additional staff training to encourage additional enrollment and ensure that the program meets the long-term goals for our members.

*National Institute of Mental Health Web site

**Study published in the September 26, 2007 Journal of the American

Medical Association, available on the National Institute of Mental Health

Web site.

From the National Comorbidity Study (NCS) survey, as reported on the

National Institute of Mental Health Web site.


Talk with your Highmark representative.

Highmark is prepared to work with you to explore

your options and develop a benefit design that

complies with the Mental Health Parity law and

meets your employees’ needs and your organization’s

budget. To get started, contact your Highmark

representative today.

Highmark is a registered mark of Highmark Inc.

blue Shield and the Shield symbol are registered service marks of the blue Cross and blue Shield Association, an association of independent blue Cross and blue Shield Plans.

McKesson, the American Society of Addiction Medicine, the National Institute of Mental Health and Mercer are independent companies that provide the services and information referenced in this brochure.




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