The Maryland Parity Project worked with the University of Maryland Drug Policy Clinic to analyze the [tippy title=”Qualified Health Plans” header=”on”]QHPs are private health benefit plans that are certified by Maryland Health Connection.[/tippy] (QHPs) for sale on the Maryland Health Connection to determine their compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA). The Clinic reviewed all 85 QHPs for sale by 4 insurance carriers in the Fall of 2013. Two clinic students obtained all available plan documents and the plans’ [tippy title=”Summary of Benefits and Coverage” header=”on”]An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans.[/tippy], from the Maryland Insurance Administration (MIA) via a Public Information Act request and then conducted a review of the financial requirements and treatment limitations to determine plan compliance.`
FINDINGS
This review uncovered significant issues with the MIA’s process for determining MHPAEA compliance. As we identified in the 2013 Maryland General Assembly session, it became clear that insurers did not submit adequate information to allow the MIA to conduct a review of whether the plan’s [tippy title=”non-quantitative treatment limitations” header=”on”]A limitation that cannot be expressed numerically. These are cost containment strategies, often referred to as care management, includes requirements such as prior authorization, step-therapy, prescription drug formulary creation, utilization review, etc.[/tippy] (NQTLs) complied with MHPAEA. Without a thorough review of NQTLs, the MIA could not ensure that consumers would receive non-discriminatory health benefits
The Clinic also identified several potential MHPAEA violations of plan financial requirements. Specifically, one carrier imposed a cost-sharing requirement for outpatient mental health and substance use disorder office visits that was higher than the comparable primary care office visit co-payment. Another carrier applied a [tippy title=”deductible” header=”on”]A specific dollar amount that your health insurance company may require that you pay out -of-pocket each year before your health insurance plan begins to make payments for claims. Under the parity regulations, plans may not implement a separate deductible for mental health or addiction treatment.[/tippy] to methadone treatment services in one plan that was not comparable to the medical services subject to the deductible.
ACTIONS
The Clinic sent letters identifying the potential MHPAEA violations and plan disclosure problems to the respective insurers and the MIA. The MIA investigated each complaint and has required the carriers to address each potential violation that the Clinic identified. The MIA also acknowledged that it is unable to complete a thorough NQTL compliance review because the information required for that review is not provided in plan documents submitted by insurers.
The Clinic informed the Maryland Health Benefit Exchange and the MIA that the QHPs for sale may not meet the ACA’s requirements that the [tippy title=”Essential Health Benefits” header=”on”] health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services comply with MHPAEA; including ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.[/tippy] It requested that the State implement a review process for 2015 plan certification that would enable it to evaluate plan compliance with NQTL requirements. The MIA pointed to administrative and resource limitations as a further barrier to this type of review but asked the Clinic to develop a reasonable set of items that insurers would be required to provide for purposes of the review. The Clinic sent the list in May 2014 and expected to continue discussions with MIA and Exchange officials to hammer out the details of the request. However, the MIA has indicated that it is unable address this issue until after 2015 plan certification.
We are now pursuing enforcement at the federal level so that the State will take action to review health plans offered in 2015 for Parity Act compliance. Under the ACA, the Center for Medicare and Medicaid Services (CMS) has authority to enforce the ACA if the State declines to do so. The Clinic is preparing a letter that requests intervention by CMS.
Other Parity Perspective posts related to parity enforcement in Maryland
1. Governor O’Malley Signs Mental Health and Substance Use Disorder Parity Legislation
2. Final Parity Rule Upholds Strong Consumer Protections
If you or someone you know is having difficulty accessing mental health or substance use disorder care in a Qualified Health Plan, please contact us for assistance.