APAPO addresses parity enforcement and transparency in Medicaid

Recent advocacy efforts are part of ongoing work related to both psychologist inclusion in Medicaid and parity implementation.

On June 9, 2015, the APA Practice Organization (APAPO) sent a letter (PDF, 87KB) to the Centers for Medicare and Medicaid Services (CMS) regarding a proposed rule that would apply the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to health insurance coverage offered by Medicaid, through Medicaid managed care organizations (MCOs), the Children’s Health Insurance Program (CHIP) and Medicaid alternative benefit plans (ABPs).

APAPO supports the application of strong MHPAEA parity protections to Medicaid enrollees receiving services through MCOs, ABPs and CHIP, and suggested additions to the proposed rule that would establish a better framework for effectively enforcing compliance.

APAPO’s suggestions for enforcing compliance included:

  1. Invest in interagency collaboration on parity enforcement and compliance initiatives, including ongoing information sharing and technical assistance. The Departments of Labor, Treasury, and Health and Human Services have accumulated a wealth of experience in jointly enforcing MHPAEA in the private insurance/self-insured market, as have some of the state insurance agencies. 
  2. CMS should provide detailed guidance to state Medicaid programs on the information requirements, documentation and reporting required to effectively demonstrate compliance. 
  3. Require that states provide documentation to CMS — and to stakeholders — to show managed care entity contracts are in compliance with parity requirements. 

The letter also addressed the issue of non-qualitative treatment limitations (NQTLs). (An NQTL is a limitation that is not expressed numerically, but otherwise limits the scope or duration of benefits for treatment. For example, a limit of 20 therapy sessions per year, a $50 co-pay or a $2,000 annual maximum is a quantitative limitation, while medical management techniques such as requiring pre-authorization to determine medical necessity are NQTLs. U.S. Department of Labor guidelines on NQTLs indicate that mental health NQTLs must be “comparable to” and applied “no more stringently than” those processes used in applying limitations to medical/surgical benefits.)

APAPO supports the inclusion of the MHPAEA NQTLs in the proposed rule for Medicaid coverage, and wants to ensure that the NQTL provisions require parity in reimbursement rates for network mental health professionals, as defined in the Final Parity Rule issued in November 2013.

Finally, the letter calls for transparency in provider reimbursement rates, and for collection of reimbursement rate information from MCOs, ABPs and CHIP. “One of the most direct, immediate, and effective methods health plans use to circumvent prohibitions on NQTLs is through reduced or chronically low reimbursement rates for mental health services,” says APA Executive Director for Professional Practice Katherine C. Nordal, PhD. “We have been working to reverse mental health treatment reimbursement rate cuts for several years, and we know that such cuts proliferated after adoption of interim final rules applying MHPAEA requirements to private sector plans.”

Background on advocacy related to Medicaid and parity implementation

As of May 26, 2015, 30 states including the District of Columbia have adopted Medicaid expansion under the Affordable Care Act. Three states are still debating the matter, and 18 have elected not to expand Medicaid. As part of the APA Practice advocacy initiative to address barriers to psychological services in Medicaid, we engaged Epstein, Becker & Green — a law firm with expertise in Medicaid and health care law — to analyze and prepare a sampling of challenges to psychological services delivery in five states (PDF, 80KB), as well as opportunities for overcoming those challenges. APAPO subsequently extended that analysis to cover every state.

Because Medicaid is a state-based program, APA Practice has supported several state-level initiatives by providing resources and APA Practice Organization grants. The APA Practice and Education directorates both provided support to the Arkansas Psychological Association in achieving reimbursement for the services provided by predoctoral psychology interns in Medicaid in the state.

APA Practice Organization grants and staff attorneys have supported states such as Kentucky, Louisiana, Minnesota, Missouri and Wyoming in their pursuit of psychologist inclusion in Medicaid expansion, and the reimbursement of health and behavior (H&B) codes. Most state Medicaid programs (as well as some private insurance carriers) still fail to cover H&B services, thus depriving psychologists of the ability to help patients address crucial behavioral aspects of physical health problems.

In September 2013, APA and APAPO sent a joint letter to the Senate Finance Committee, which, among other suggestions, called for making the provision of psychological services mandatory under the Medicaid program in order to promote patient choice of provider and allow access to the full range of psychological services, and requiring Medicare/Medicaid reimbursement for doctoral psychology interns, residents and post-doctoral trainees.

On May 4, 2015, the DC Psychological Association (DCPA) and APAPO staff met with the interim D.C. Medicaid director and staff from the Department of Health Care Financing (DHCF) to discuss the issue of allowing for the independent provision of psychological services by licensed psychologists and the reimbursement of covered services provided by psychology interns within the Medicaid system. That meeting led to the scheduling of a joint meeting on June 10 with the director of the Department of Behavioral Health (DBH) to further discuss these issues.

Additionally, APA’s Education Directorate recently hired a policy and advocacy fellow to work on a Psychology Internship Reimbursement Project with the Practice Directorate. The purpose of the Internship Reimbursement Project is to work with individuals and representatives of state, provincial and territorial psychological associations (SPTAs) to develop and implement strategies to increase the sustainability of internship programs by advocating for changes to allow for reimbursement from Medicaid for psychological services provided by doctoral psychology interns supervised by licensed psychologists. The fellow will also explore avenues to create reimbursement for independently practicing licensed psychologists and their ability to bill using Health and Behavior (H&B) codes.

APAPO has also made implementation and enforcement of the MHPAEA a top priority. In early May 2015, APAPO joined 16 other parity stakeholder organizations, including NAMI, Mental Health America, the American Psychiatric Association and National Council, on a letter to the federal parity agencies (the departments of Health and Human Services, Labor and Treasury) regarding the organizations’ shared concerns about full implementation and enforcement of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). This is one of many comments on parity issues that APAPO has submitted to federal and state agencies.

In response to a request from the U.S. Department of Labor, the APA Practice Organization (APAPO) submitted a comment letter on Jan. 8, 2014, addressing concerns related to implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). APAPO addressed the issues of compliance and transparency, along with several other issues, building on our 2010 comment letter about implementation of the interim final rule (IFR) about mental health parity and our April 2013 letter on how to make the final rule more enforceable.

Collaborating with state associations, APAPO has filed more than a dozen parity complaints or inquiries with state and federal parity enforcement agencies and with health insurers. It has also met with the federal enforcement agencies to press for enforcement on those complaints and to address other emerging parity issues. APA has also [developed a guide to help consumers understand their rights] under MHPAEA.

For more information on Medicaid or parity implementation, contact the Office of Legal and Regulatory Affairs by email or at (202) 336-5886.