• Mental Health Parity & Addiction Equity Act & Medicaid
• NY Attorney General on Mental Health Parity
• ​Parity, Assertive Community Treatment & Discrimination
• Parity & the CO Dept. of Health Care Policy & Financing

Andrew Romanoff, CEO of Mental Health Colorado. Photo Credit: The Coloradan

So where are the treatment limitations in CO Medicaid Mental Health that are more restrictive than medical/surgical benefits?

• Medical Management Standards
• Provider Reimbursement Rates
• Refusal/Inability to pay for higher cost therapies  — really it’s beyond a “Fail-First Policy” – it’s a “Fail Policy.”
• Exclusions [including defacto exclusions] based on failure to complete a course of treatment [or get along with the staff.]
• Restrictions based on facility type 
• Other criteria that limit patient access to intensive mental health services – mainly that there is a shortage of such services.
• Our perspective is the tier design of CO Medicaid Mental Health Services is grossly inadequate for those needing the most intensive services and placements. AND what happens?  People wind up in jail or homeless.

So what are we trying to say here?  We are having some fun @ the State’s expense.

Pretty much everybody knows that Colorado does not have Parity or Medicaid Network Adequacy, including individuals, family members, professionals, the media,  Mental Health Colorado that just gave Gov. Hickenlooper an award, and likely even the State itself.

But we’re SUPPOSED TO HAVE Parity and Medicaid Network Adequacy — so we can’t say we don’t, right?

The thing is there is nothing that horrible that is going to happen if we do acknowledge it.

It’s coming up with a plan to fix it ideally with Stakeholder participation that complies with the Law and move on down the road.

As we’ve said before, the boring truth is — if you fix it — people will stop bothering you.

42 CFR 457.496 – Parity in mental health and substance use disorder benefits.

(4) Nonquantitative treatment limitations –

(i)General rule. A State plan may not impose a nonquantitative treatment limitation for mental health or substance use disorder benefits in any classification unless, under the terms of the CHIP State plan as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation for medical/surgical benefits in the classification. 

1. Illustrative list of nonquantitative treatment limitations. Nonquantitative treatment limitations include –

(A) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;

(B) Formulary design for prescription drugs;

(C) For plans with multiple network tiers (such as preferred providers and participating providers), network tier design;

(D) Standards for provider admission to participate in a network, including reimbursement rates;

(E) Plan methods for determining usual, customary, and reasonable charges;

(F) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols);

(G) Exclusions based on failure to complete a course of treatment;

(H) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; and

(I)Standards for providing access to out-of-network providers.

CMS Document:

October 11, 2017:​
​
​​The final rule requires that all beneficiaries who receive services through managed care organizations, alternative benefit plans, or CHIP be provided access to mental health and substance use disorder benefits that comply with parity standards, regardless of whether these services are provided through the managed care organization or another service delivery system.

States are required to include contract provisions requiring compliance with parity standards in all applicable contracts for these Medicaid managed care arrangements that provide services to enrollees in managed care organizations, including prepaid inpatient health plans or prepaid ambulatory health plans.

In contrast to the proposed rule, this final rule also extends parity protections to apply to long term care services for mental health and substance use disorders in the same manner that they are applied to other services.

Key Provisions for Medicaid Managed Care Organizations Under the final rule, states that have contracts with managed care organizations are required to meet the parity requirements regarding financial and treatment limitations consistent with the regulation applicable to private insurers.

States will include the cost of providing additional services or removing treatment limitations in their capitation rate methodology for affected managed care plans. 

By allowing changes to the managed care rate setting process, the rule also provides each state with flexibility to enable Medicaid managed care organizations to fully comply with the rule by including additional costs necessary to include extra services or remove treatment limits without changing the state’s non-alternative benefit plans and state plan.

​ In addition, the final rule requires managed care entities to make available upon request to beneficiaries and contracting providers the criteria for medical necessity determinations with respect to mental health and substance use disorder benefits.

The rule also directs managed care plans to make available to the enrollee the reason for any denial of reimbursement or payment for services with respect to mental health and substance use disorder benefits.