Managed Care - November 2008 - (Page 8)

LEGISLATION & REGULATION Mental Health Parity Leaves a Lot Out Though the legislation isn’t comprehensive and won’t be a burden, some health plans will need to scramble to build specialist provider networks By John Carroll F If you are in a state with a strong parity law, you probably won’t have to do very much to comply, says Andrew Sperling of the National Alliance on Mental Illness. or an estimated 113 million Americans, the $700 billion congressional bailout bill carried a sweetener in the form of a mental health parity bill that is designed to evenly balance the way health insurance covers medical and behavioral health benefits. Eighty-two million are covered by self-insured health plans and another 31 million are in plans that are subject to state regulation. After more than a decade of debate, it will soon be up to employers and the managed care industry to erase the limits on inpatient days or outpatient provider visits that had commonly been used to control mental health benefit costs. They effectively have until next summer to restructure benefit designs and adopt a different set of cost-control tools. “The bottom line cost to health plans is probably going to be small,” says Frank McArdle, a health policy expert at Hewitt Associates, citing a Congressional Budget Office estimate of a 0.2 percent increase. “Our estimates are close to that, but there will have to be a lot of plan redesign work to comply with the new standards.” There are some important things that the law doesn’t do. It doesn’t apply to businesses with 50 or fewer workers, leaving the parity requirements to larger employers that were more likely to offer the benefit to begin with — and most likely to keep it. Even so, companies don’t have to offer mental health or substance abuse benefits at all under the new law and they can still specify which conditions are covered when the law takes effect at the beginning of 2010. Health plans that are affected may have to adjust the amount a member pays. If a visit to a specialist calls for a $35 copayment, the same might apply for a mental health visit. According to the law, says Greenberg, parity on mental health benefits will mean out-of- pocket costs that are “no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits.” She assumes that means that the terms on mental health will need to be on par with the way medical specialists are currently covered in the plan, but that has to be clarified in the regulations. “Plans might get creative here,” she adds. “But I don’t know. That’s why the regulations [yet to be issued] have to give some direction.” In balancing the financial burden, plans are free to raise the cost of the medical benefit — no cuts are required. As with the medical benefit, any denial of service under a plan’s medical necessity rule will have to be spelled out to members. “One important thing here is that the law doesn’t apply to the small employer market, where you’re more likely to see explicit limitations today,” says Kris Haltmeyer, managing director of policy analysis at the Blue Cross & Blue Shield Association. “But even in the large employer market, day or visit limits or other limitations are fairly common, so that even in those plans, you’ll have to make modifications to ensure that benefits are offered at parity.” Some states may be prompted to put a new law on the book that spells out a mandate. Mental health advocates say that where they can, plans are likely to use whatever cost-control tools they have to rein in costs legitimately. That push includes putting together new networks of mental health providers and negotiating the most favorable contracts they can — a central feature of every MCO’s business model. Managing the costs “Managed behavioral health companies are going to be looked at more heavily,” says Halt- 8 MANAGED CARE / NOVEMBER 2008

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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