Summer 2009

Federal Mental Health Parity Implementation Dates Approaching

Obtaining mental health parity has been a long struggle beginning in 1992 with the introduction of the first mental health parity bill during the 102nd Congress. Many mental health/substance use disorder (MH/SA) professionals and advocates, including Magellan, supported this and subsequent efforts culminating in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. While implementation could begin as early as October 3, 2009, most covered members can expect the mental health parity changes on January 1, 2010.

As we approach the implementation dates, Magellan wants to facilitate a smooth transition for our providers by offering information about the new federal parity requirements to promote your understanding of the law and the steps necessary to continue to obtain care for covered members.

Parity Basics

The new federal parity law builds on the 1996 law that equalized aggregate lifetime limits and annual limits between medical and mental health services. The new law includes substance use disorders benefits in addition to mental health benefits, and addresses both financial requirements and treatment limitations.

A health plan may not apply separate cost-sharing requirements or treatment limitations that are applicable solely to MH/SA disorder benefits.

• Financial requirements and treatment limitations for behavioral benefits must be no more restrictive than medical/surgical benefits for employers with more than 50 employees including:

• Copayments, co-insurance
• Days, visits
• If the plan provides out-of-network benefits for medical/surgical coverage, then the plan must do so for behavioral coverage too.

• The new federal parity law does not:

• Require MH/SA benefits
• Dictate levels of care, covered diagnoses, or exclusions and limitations
• Control or dismiss utilization management processes, procedures or requirements
• Apply to all covered members.

Provider Actions

• Continue to call the number on the back of the member’s insurance card to determine benefit limits. Don’t assume everyone you see has benefits subject to the new federal parity requirements.
• Federal parity does apply to Medicaid managed care plans, employer/union plans that cover more than 50 employees and provide MH/SA benefits (both self-insured and group health plans), and State Children’s Health Insurance Programs (SCHIP).
• Federal parity does not apply to individual health insurance policies, Medicare, employer plans with 50 or fewer employees, employer or health plans with no MH/SA benefits, employer health plans that successfully meet the cost exemption, and self-funded governmental employer plans that elect not to comply.

• Continue to participate in utilization management processes. While benefit coverage plan designs may be revised by our customer health plans, Magellan’s utilization management processes, such as precertification and concurrent review, will continue but may change somewhat. You will be notified well in advance of any change.
• Continue to reference Magellan’s medical necessity criteria available on this website. This information and reasons for payment denials will be available to participants, beneficiaries or providers on our website and/or upon request. Remember, while MH/SA benefits must be no more restrictive than medical, which may mean unlimited visits, coverage still requires meeting medical necessity criteria.

“The implementation of the long-awaited federal mental health/substance abuse disorder parity act offers a unique opportunity for most providers and consumers of behavioral health services,” said Dan McCarthy, Ph.D., Magellan’s chief clinical officer. “Providers who take care to understand the parity act and associated utilization management requirements will contribute to a successful implementation.”