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Young battle managed care barriers

April 1, 2014
by Alison Knopf
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Part 1 of a 3 part series
Mark J. Covall

Some of the hardest-hit patients in managed behavioral health care are young people who are unable to access adequate services for psychiatric disorders. It’s not that they don’t have health insurance—they do—or they are covered under their parent’s policies thanks to the Affordable Care Act whereby children up to age 26 can be covered by their parents’ insurance.

The barrier is that managed care’s utilization review and medical necessity provisions make such care unaccessible.

The final rule implementing the Mental Health Parity and Addiction Equity Act (MHPAEA) addresses “to some degree” problems with bringing residential care into the parity paradigm, says Mark J. Covall, president and CEO of the National Association of Psychiatric Health Systems (NAPHS), which represents hospitals and a range of community-based mental health and addiction facilities.

“We think that’s an important step forward,” Covall told Behavioral Healthcare. However, that final rule doesn’t take effect until plan years beginning in July, which for all intents and purposes means plans beginning in January 2015. “So we’re still in that period where the final rule isn’t effective yet,” he adds.

Although paperwork barriers are the most problematic for young people seeking intermediate levels of care that are residential, partial hospitalization, and intensive outpatient, non-quantitative treatment limitations (NQTLs) continue to create barriers to care.

NAPHS is working with the Parity Implementation Coalition (PIC), which is co-chaired by Irvin Muszynski of the American Psychiatric Association and Carol McDaid of Capitol Decisions, a boutique Federal Government affairs firm. Under the efforts of the PIC, the quantitative treatment limitations – day and dollar limits to mental health and substance use disorder (SUD) services that are more stringent than those for medical/surgical services – have almost disappeared.

“But when we get into the grayer area of the NQTLs, it’s more difficult,” says Covall. “The NQTLs include utilization review, medical-necessity criteria, and fail-first in which patients are told they have to go to outpatient first, and “fail” -- before intermediate or inpatient treatment will be authorized.”

Although NQTLs were banned by the interim final rule implementing the MHPAEA, and by the final rule issued last fall, most health plans are still using them, adds  Covall. “In talking to my members, we see little change in the NQTL area,” he said. NAPHS is working with the PIC on some strategies on enforcement.

Read part 2, Parity complaint process difficult to complete.