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Parity Violation

The Mental Health Parity and Addiction Equity Act (federal parity law) doesn’t require that mental health and substance use disorders be a covered benefit. But the combination of other Maryland and federal laws in effect mean that mental health and substance use disorder treatment must be covered. There are few, if any, insurance plans provided to Maryland residents that can legally say that they don’t cover any mental health or substance use disorder treatments.

Nothing below is automatically a parity violation, but any of the examples or scenarios may indicate a potential violation of the parity act and should be explored further. This often means asking the insurance company for more information.

Quantitative Limitations

*Violations in this area are very rare in Maryland*

  • The complete exclusion of any level of treatment, such as residential, for either a mental health or substance use disorder.
  • Higher co-payments or separate deductibles for behavioral health services.In Maryland, most outpatient co-payments for behavioral health should be the same as for primary care.
  • Blanket limit on the number of outpatient visits or days for an inpatient stay.Unless a plan also has a limit on the number of visits you can make to a primary care doctor or the number of hospital inpatient days regardless of condition or illness, it cannot have them for behavioral health. The plan can use an authorization requirement to determine how many visits or inpatient days are medically necessary for a given condition or situation.

Non-Quantitative Limitations

*These scenarios are more common in Maryland*

  • Frequent or time-consuming authorization processfor outpatient or inpatient care. If the process to obtain authorization for treatment seems burdensome, it might be a parity violation.
    • Example: Smith provides outpatient mental health services and has become increasingly frustrated by ABC insurance company’s requirement that he obtain authorization after every 20 sessions with a client no matter the severity of their mental illness. Not only must he submit an electronic authorization, but he is often required to submit a new treatment plan and then justify the continuation of treatment on a 30-60 minute phone call with an insurance company representative.
    • Example:Natalie was admitted to XYZ hospital’s inpatient psychiatric unit after presenting at the Emergency Room with severe depression and thoughts of harming herself. The admitting physician submitted an authorization for the recommended stay of 7 days. Natalie’s insurance company did not deny the stay, but only authorized 3 days. After the 3 days, the attending psychiatrist or hospital social worker must submit another authorization, requiring the psychiatrist to justify the stay on a 60-minute phone call with the insurance company. The insurer authorized 2 additional days. Although the total authorized time of 5 days doesn’t reach the originally recommended 7 days of inpatient treatment, a denial of treatment is not sent. Natalie can still appeal this decision to not authorize a longer inpatient stay.
  • Requirement that a client have failed at a lower level of treatmentprior to authorizing a more intensive level of care.
    • Example:ABC insurance company’s medical necessity criteria for residential treatment states that the patient must have a documented history of failure at a lower level of care, such as outpatient or intensive outpatient treatment. Effectively, this means that ABC will not authorize residential treatment unless the patient has previously failed at outpatient or intensive outpatient treatment.
  • Requirement to obtain authorization for inpatient or residential treatment – the client must be likely to demonstrate improvement.This is often more likely to be seen for residential substance use disorder than for mental health treatment.
    • Example:Bob sought residential rehab treatment for his heroin addiction. During his assessment, the treatment facility found that Bob may also have an addiction to alcohol. Bob does not believe he needs treatment for alcoholism, but is very ready to enter a 28-day program for his heroin addiction. Bob’s assessment notes were included in the authorization request to his insurer. They have denied authorization for treatment as they have determined Bob is not likely to show improvement because he is reticent to accept treatment for his alcohol use.
  • Blanket prior authorization requirement for all prescription drugsused in substance use disorder treatment. New MD law taking effect 2018 prohibits insurers from instituting a prior authorization for opioid treatment medications. Therefore, plans in 2018 that require this would be violating Maryland law, and a complaint should be filed with the Maryland Insurance Administration.
  • Requirement that provider implement treatment contract with consequencesfor any opioid medication assisted treatment.
    • Example:ABC managed care organization requires that prior to any patient receiving a prescription for buprenorphine to treat their heroin addiction they must have an active treatment contract with the prescriber. The agreement must outline the provisions of the contract {no use of other substances, attendance and weekly counseling sessions, etc.} and must have consequences for violations of the contract, such as mandatory group or additional session if the patient has a positive urine screen for another substance {marijuana or benzodiazepines}.
  • Other requirements that might violate parity, but are more likely noticed by providersinclude the way that insurers determine the rates they pay providers for the different services; the criteria that insurers use to determine when they are closing panels and not accepting more providers in the network; and onerous and limiting credentialing and paneling requirements for providers to join networks.

 

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