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LEGAL & POLICY IMPLICATIONS FOR TREATMENT IN 2014 & BEYOND
Carol McDaidCapitol Decisions, Inc.February 10, 2014, AXIS Conference
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Overview of the Presentation
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Parity & ACA: Legal & Policy Implications for Treatment for 2014 & Beyond Parity
Federal parity implementation: a chronology Opportunities & challenges Why is parity important to treatment providers? Key provisions in MHPAEA Final Rule Tools for providers: MHPAEA implementation & enforcement Implications for providers & facilities
Changing business practices to optimize MHPAEA & ACA
Affordable Care Act Medicaid expansion The Exchanges
Parity & ACA Chronology3
The Mental Health Parity & Addiction Equity Act (MHPAEA) becomes law; fully effective 1/1/2011
The Affordable Care Act (ACA) becomes law
MHPAEA final rule released on 11/8/13; applies only to
commercial plans
2008 2010 2013
EHB rule requires SUD as 1 of the 10 essential benefits. Parity applied in & out of exchanges to non-grandfathered plans
CMS issues guidance applying parity to MMCOs & CHIP unless state plan permits discriminatory limits
Opportunities
Largest expansion of addiction coverage and reimbursement in a generation
Medicalization, not criminalization, of substance use disorders
Stigma and discrimination reduced Equitable reimbursement and provider
networks for providers and specialists
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Challenges
Like building and flying an airplane at the same time
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Challenges in Detail
26 states expanding Medicaid Highly politicized environment in state-
federal structure Less than ½ of states fully implementing
ACA Much of the promise of parity & ACA
based on state decision-making Landmark laws historically take decades
for full implementation
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Why is parity important to treatment providers?
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Coverage ≠ access MHPAEA requires parity in care management;
most state parity laws do not Parity provides a rationale for equitable use of
MAT for SUD Without parity, behavioral health cost shift from
private to public sector continues while federal funding drops due to ACA
Rationale for equal levels & types of care in hostile reimbursement environmentStrategy: Encourage DOI to do annual MHPAEA compliance audit like Connecticut’s
MHPAEA Final Rule: Who & When• The rule does not apply to Medicaid
managed care, CHIP and alternative benefit plans (more guidance is coming) but law does
• Continues to allow local & state self-funded plans to apply for an exemption from MHPAEA
• Applies to the individual market (grandfathered & non-grandfathered plans)
• Effective for plan years on or after 7/1/14 (1/1/15)
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MedicareTraditional fee-for-service Medicaid
FEHBPTRICAREVA
MHPAEA Does Not Apply To
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MHPAEA Final Rule: Scope of Services Big win for intermediate services (IOP,
PHP, residential) Clarified scope of services issue by
stating: 6 classification benefits scheme was never
intended to exclude intermediate levels of care MH/SUD services have to be comparable to the
range & types of treatments for medical/surgical within each class
Plans must assign intermediate services in the behavioral health area to the same classification as plans or issuers assign intermediate levels for medical/surgical
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MHPAEA Final Rule: NQTLs
Strikes provision that permitted plans to apply limits if there was a “clinically recognized standard of care that permitted a difference”
NQTLs are expanded to include geographic location, facility type, provider specialty & other criteria (i.e. can’t let patients go out of state for med/surg treatment and not MH/SUD)
Maintains “comparably & no more stringently” standard without defining the term
Confirms provider reimbursement is a form of NQTL
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MHPAEA Final Rule: Disclosure & Transparency Requires that criteria for medical necessity
determinations be made available to any current or potential enrollee or contracting provider upon request
Requires the reason for a denial be made available upon request
Final rule now requires plans to provide written documentation within 30 days of how their processes, strategies, evidentiary standards & other factors were used to apply an NQTL on both med/surg & MH/SUD
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MHPAEA Final Rule: Enforcement Final rule clarifies that, as codified in
federal & state law, states have primary enforcement over health insurance issuers
DOL has primary enforcement over self insured ERISA plans
DOL, HHS & CMS will step in if a state cannot or will not enforce the law
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Implications
Laws are not self-implementing Coordinated effort between providers,
patients & industry to fully implement & enforce groundbreaking laws
Requires well coordinated networks at state & federal level with common messaging
Sharing effective ACA & parity implementation strategies & replicating successes
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Strategy: Urge providers & consumers to engage in parity education & advocacy
Changing Business Practices to Optimize Parity Benefit Verification
Patients should sign release permitting treatment center to be their “authorized representative” with health plan for purposes of obtaining plan documents
As authorized rep, seek a complete copy of patient’s health plan – to compare medical & behavioral benefit
Train benefit verification staff on MHPAEA final rule prior to its full implementation date (plan years on or after 7/1/14)
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MHPAEA Training at All Levels Benefit verification staff
Training should include: quantitative & non-quantitative treatment limits, scope of services, prohibitions on facility type & geographic limitations
Staff should know & tell self-insured plans employer is liable for MHPAEA violations
Regularly appeal denied claims; templates available at www.parityispersonal.org
Clinical Staff Documentation must conform to medical necessity
criteria Senior staff
Should be trained in basics of MHPAEA; market will not change unless we are informed ambassadors & drive change
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State & Local Advocacy
State and local advocacy must be better coordinated to drive state and federal enforcement of MHPAEA and ACA
State and national trade associations should have common goals and strategies for parity & ACA implementation and enforcement
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Resources
Resources available at www.parityispersonal.org: URAC parity standards Massachusetts parity
guidance Connecticut compliance
survey Maryland parity laws Nebraska parity compliance
checklist Milliman employer & state
guide to parity compliance Toolkit for appealing denied
claims
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Additional Resources
States & public plans CMS Center for Consumer Insurance Information &
Oversight (CCIIO) 877-267-2323 ext 61565 E-mail: [email protected]
Employer plans DOL Employee Benefits Administration 866-444-3272 www.askebsa.dol.gov
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Affordable Care Act & Parity
On 1/1/14*, ACA expanded MHPAEA & parity applies to: Benefits provided in new “exchanges” Benefits provided by non-grandfathered small
group & individual plans Benefits provided to new Medicaid population These plans will have to offer a MH/SUD
benefit
*The Administration is allowing canceled plans (that didn’t meet these requirements) to continue to be offered in 2014; adherence will vary by state
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Controversial ACA Provisions
“If you like your plan, you can keep it”
Medical device tax 2.3% tax on health
plans Individual mandate &
fines Coverage for
contraceptives
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Who is enrolling in the exchanges? 65 percent previously uninsured More than one-third have not had a check-up
for more than two years Lower income than those currently covered by
private insurance More racially diverse than the those who
currently have private insurance One in four Exchange enrollees speak a
language other than English at home 77 percent of people enrolled through
Exchanges have a high school diploma or less
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Source: Department of Health and Human Services, 2013; Sam Baker, “Three Things You Should Know About the Latest Obamacare Numbers,” National Journal, January 13, 2014.
Showing Signs of Improvement, Federal Exchange Numbers and Total ACA Enrollment Spiked in December
Analysis
• In December, there was a sevenfold increase in federal exchange enrollments
• In December, there was a threefold increase in state exchanges
• While state exchanges saw the most success in the opening two-month period, total enrollment in the federal exchange now outpaces total enrollment in state-based exchanges by 25%
• The rise in enrollment is due in large part to Dec. 24 deadline for Jan. 1 coverage and technical repairs to HealthCare.gov
• Overall, ACA enrollment in both state and federal exchanges have undergone a fivefold increase; 1,788,739 additional people selected plans in December
• The cumulative, three-month ACA enrollment total is 2,153,421 people
Health Insurance Exchange Enrollment by Month
Monthly Total:106,185
Monthly Total:258,497
State exchanges Federal exchanges
Monthly Total:1,788,739
Oct. 2013 Nov. 2013 Dec. 2013
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What can you “buy” on the exchanges? “Qualified Health Plans” (QHPs)
Private insurance plans Must cover “essential health benefits” Must offer certain levels of value (“metal
levels”) Must include “essential community
providers,” where available, in their networks Must have provider network sufficient to ensure
access to MH/SUD services without “unreasonable delay”
Must comply with ACA insurance reforms
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Strategy: Get copies of QHP benefit packages & verify packages are ACA & MHPAEA compliant
How MHPAEA Applies to Exchanges
Per recent guidance: Plans offered in the exchanges will be required
to offer a mental health & addiction benefit at parity
“New” individual & small group plans (plans not in existence on 3/23/10) will also have to offer mental health and addiction at parity
ACA data regs require plans to report on quantitative treatment limitations
MHPAEA guidance requires reporting of NQTLs
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Strategy: Make sure exchange requires QHP reporting of BH financial & other treatment limits
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Parity & Medicaid Expansion
January 2013 Medicaid parity guidance Medicaid MCO plans must comply w/parity unless state
plan allows discriminatory limits Benefits for the “newly eligible” Medicaid population
must include MH/SUD at parity Parity final rule does not apply to MMCOs, CHIP & ABPs
PIC asking for new guidance on application of final rule within 6 months or by 7/1/14
CMS guidance available at: http://www.medicaid.gov/Federal-Policy-Guidance/Federal-Policy-Guidance.html
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Strategy: Advocate for CMS parity guidance applying final rule by 7/1/14
UNDERSTANDING AND IMPLEMENTING NEW LEGAL REQUIREMENTS
Anelia ShaheedMed Pro BillingFebruary 10, 2014, AXIS Conference
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Overview of the Presentation
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What will the ACA do to my business ? New Patients, Policies and Coverage? New Legal Requirements by the State and Federal Govt?
What will the expansion of Medicare/Medicaid do to my business ?
What should I expect from Insurance Companies ? In Reimbursement Performance Requirements Utilization Review and Medical Records
What am I as a provider required to comply with ?
Overview of Insurance 30
Benefits Verificati
ons
Utilization Review
Billing and
Collections
Importance of Understanding Legal and Ethical Business OperationsWhether New or Experienced, every
provider in every sector of the mental health and substance abuse industry will undergo changes in the upcoming years.
It is important that all areas of your business meet your state and federal guidelines for ethical and legal compliance
Mental Health and Substance Abuse is moving into the realm of national scrutiny
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What will the ACA do to my Business?
New Patients and New Policies ACA policies vary by state, depending on
whether they have initiated own state policies or adopted Federal polices
If you take insurance now you can continue taking these policies
These policies have both IN and OUT of network benefits
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What will the ACA do to my Business?
As of today there is no change in Medicare recognizing Medicare allowables for primary substance abuse diagnosis in a facility setting
Insurance companies have reporting requirements to participate and performance requirements which means those restrictions will be passed along to you. Increase in number of medical records and
third party audits. This can be a good thing !
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What will the ACA do to my Business?
Under ACA, you do not have to be a Medicare or Medicaid provider in your state to perform services for policies that are sold under the exchanges. Normal state licensing or insurance
company requirements will still apply and may be come more stringent
Under ACA, you can continue to accept self-pay and cash payments However, if you are balance billing or
offering scholarship you must legally compliant with the provision of the Act
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Legal Requirements for Balance Billing
Medicare and Medicaid Patients and Providers Some states and plans specifically prohibit
amount that may be balanced billed by providers if assignment is on file
Notice of Balance Billing and Collections Any Bill, Statement or Attempt to collect
even if by a provider should be compliant with the Fair Debt Collections Act
In- Contracts strictly can prohibit balance billing
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Legal Requirements for Marketing and Scholarships
Healthcare Enticement and Kickbacks Scrutiny of ownership interest in business
(check with your state) Federal requirements – must be for services
rendered not just referrals State requirements – specific states have
guidelines for Kickbacks Write Off/ Scholarships
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What should I be careful of?
Increased scrutiny by Insurance Companies
Increase in no of audits / medical records Increase in no of individuals covered by
gov’t funding which means as a provider requirement to be compliant with Federal/State req.
Decrease in willingness to contract Decrease in traditional methods of
service by insurance companies (HITECH)
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What will the Expansion of Medicaid Do for MH/SA
Short Answer…. Increase in individuals covered Not be an immediate source or revenue
If you choose to provide service these individuals all Federal and State practices and requirements apply
New carve-outs through private insurance companies (ValueOptions/BCBS) for Medicaid/Medicare
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What will Insurance Companies Do?
2013 – Delay of large group implementation / Drops of single individual policies
2013 – Majority of commercial insurance companies will treat ACA policies as commercially priced services
Expect the continuation and increase in allowables (are allowables legal ????)
2014 – Implementation of Large Group
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What will Insurance Companies Do?
What will affect Reimbursement Models Allowables and Usual and Customary…
what do these mean legally? Disclosure requirements.. I can get
information on behalf of the patient but how?
Reporting requirements.. Insurance companies can loose their ability to sell policies and must report information to gov’t.
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What will Insurance Companies Do?
What will affect Reimbursement Models Provider contact with Insurance
Companies Utilization Review is going to be difficult /
published criteria and ability to appeal CARF and JACHO and other new policy
restrictions
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A Business What Do I need to Do?
Financially Valid and Accurate Licensure from State Clear Financial Documentation for Billing
Insurance and Self Pay compliant with federal and state guidelines
Clear authorization to legally act on behalf patients and subscribers
Clear documentation and procedures for handling patient information
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A Business What Do I need to Do?
Clinically Appropriate Licensure for Clinically staff,
scheduling and oversight A GOOD MEDICAL RECORD
(documentation of medical necessity)
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A Business What Do I need to Do?
Administrative / Accounting Clear and Compliant protocol for
statements, balance billing and scholarship (must be Federal and specific to the state you perform services)
Clear protocols for collection efforts Documented audits and procedures for
ensuring insurance billing compliance Documented procedures for hardship
letters Tracking your receivables !
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A Business What Do I need to Do?
Administrative / Marketing Copyright and Trademark protection If using a third party vendor / clear
distinct separation from organization and contractual compliance with state guidelines
If using a employee / clear documentation that employee is not being paid for referral but for employee related services
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A Business What Do I need to Do?
Administrative / CEO Liability Ensure proper and legal authorities in
your state retain ownership interest (Dr. v. Individuals)
Limited Liability ! (LLP, LLC) Proper Liability Insurance, EPI Insurance,
HIPAA and HITECH insurance, PL insurance
Proper administrative safe guards in place for all areas of the business… provided by a good attorney and accountant who KNOWS HEALTHCARE
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Questions?
Med Pro Billing1-800-990-0340
www.medprobill.com
Melissa [email protected]
President
Anelia Shaheed, Esq. [email protected]
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