Mental health parity disclosure war: 4 battlefields

The companies fear that they may suffer from an enormous administrative burden if they have to release complex, proprietary medical necessity criteria information for all of the many different plans they operate, Greenberg says.

The ABHW says regulators may be able to help the behavioral health benefits companies by limiting the scope of the disclosure provisions and working with accreditation companies to develop widely accepted disclosure standards.

“Individuals could, for purposes of determining parity compliance with the disclosure requirements, simply check with the accrediting bodies to ascertain whether their health plan was in compliance instead of requesting a multitude of complex technical documents and attempting to make the compliance determination themselves,” Greenberg says.

See also: New York announces mental health parity settlement

2. Care providers worry the benefits companies will use “proprietary information” as an excuse to slam the door in their face.

Katherine Nordal, an executive at the American Psychological Association Practice Organization, says her group has run into some carriers that refuse access to medical necessity criteria by saying they have bought the criteria from an outside vendor.

The MHPAEA disclosure provision, Section 512, “contains no exception for proprietary criteria,” Nordal says. “If it did, companies could nullify this important transparency provision by all switching to proprietary medical necessity criteria.”

See also: Medicare’s Bill for Artificial Feet is Questioned

3. Patient and provider groups say the benefits companies should give medical necessity information to all actual and potential patients, not simply to patients affected by benefits denials.

Nordal notes that MHPAEA Section 512 requires the benefits companies to provide medical necessity criteria information “to any current or potential participant, beneficiary, or contracting provider upon request.”

“Providing criteria only when the company has denied coverage and/or providing only the criteria used to evaluate a coverage decision flies in the face of the requirement that medical necessity criteria be given to potential plan participants, beneficiaries or providers who request them,” Nordal says.

The benefits companies argue that forcing them to release too much information could help providers who want to game the system and collect payments for services that are not medically necessary.

See also: CMS: States control Medicaid autism benefits package

4. Patient and provider groups want strict rules on how quickly plans must provide the medical necessity criteria.

Laura Goodman talks about the time issue in a letter filed on behalf of a group that includes a number of Massachusetts organizations, including the Massachusetts chapter of the National Alliance on Mental Illness and Boston Children’s Hospital.

She says the groups want regulators to apply ERISA disclosure timeliness rules to the individual policies and small-group plans that now must comply with the MHPAEA parity rules.

“Large group health plan administrators are required to provide health plan members with copies of health plan information, at no charge, within 30 days of the request,” Goodman writes. “And, if health plans fail to provide the requested information within thirty days, plan administrators are subject to a penalty of up to $100 per day until the requested information is furnished. We encourage the departments to establish a similar disclosure requirement for health plans subject to MHPAEA. For example, if a health plan member makes an oral or written request for health plan information relating to the coverage of mental health and/or substance use disorders, the health plan must provide copies of all of the requested information within 30 days or else be subject to a monetary penalty of not less than $100 per day that the information is not provided.”