Corona, CA: Action in Three Behavioral Health Policy Areas

The National Association of Psychiatric Health Systems (NAPHS) Board of Trustees this week made recommendations in key policy areas that have the potential to significantly improve the lives of individuals with mental and additive disorders. The meeting (led by Board Chair Blair Stam, executive vice president, Signature Healthcare Services, Corona, CA) resulted in Board actions and discussion around three issues.

Parity Implementation

The U.S. Departments of Labor, Treasury, and Health & Human Services should issue a final rule by the end of this year on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, the Board recommended. The final rule should specifically address scope of service, Medicaid managed care, and non-quantitative treatment limits, the Board found.

Since January 1, 2011, as required in the parity law, NAPHS members have seen health plans change/eliminate arbitrary treatment limits, such as limiting inpatient care to 30 days annually. However, NAPHS members have seen less change in the area of non-quantitative treatment limits. For example, health plans continue to tightly manage the benefits by authorizing only a couple of inpatient days and then requiring the hospital's doctor to justify additional days with the health plan's doctor. This is not done for other medical conditions. NAPHS members have also seen some health plans actually reduce coverage for certain levels of care, such as residential treatment, which is contrary to the intent of the federal parity law. Medical plans generally cover all levels of care from hospital to subacute to outpatient, and – under the parity law and regulations – a similar set of levels of care needs to be provided for mental health and addiction care. To date, the Department of Health & Human Services has not issued guidance to states regarding the interrelationship between the federal parity law and regulations and Medicaid managed care. In November 2011, the federal agencies issued subregulatory guidance. "While this is a good first step toward clarifying the intent of the law, many questions remain," noted NAPHS President/CEO Mark Covall. "Consumers deserve and need clarification to ensure that the landmark parity legislation is implemented as Congress intended."

Oversight of Dual-Eligible Demonstrations

To ensure consumers protections as demonstrations are being rolled out for coordinating care for "dual eligibles" (that is, individuals enrolled in both the Medicare and Medicaid programs), the NAPHS Board recommended that Congress provide strong, ongoing congressional oversight. There are many questions that need to be answered before moving in a new direction with a particularly vulnerable population, the NAPHS Board said, including questions about the enrollment process, network adequacy standards, and overall payments. The NAPHS Board outlined broad patient-protection themes that it believes all state demonstration proposals should include:

•Enrollment in dual-eligible demonstrations should be voluntary through an opt-in enrollment (and not an opt-out enrollment).

•There should be an out-of-network option.

•Payments should not fall below the cost of delivering the care.

•States being approved for demonstrations should be encouraged to conduct pilot demonstrations in limited geographic areas (instead of implementing immediate state-wide initiatives) because of the complexity of this population and the lack of full knowledge on the best ways to proceed.

•Several demonstration approaches should be tested. Specifically, CMS should approve sufficient numbers of both types of demonstrations suggested in their January 2012 Capitated Demonstration Guidance (both the capitated model and the managed fee-for-service model).

•Getting the demonstrations right is more important than getting them implemented by the end of the year.

NAPHS will be submitting more detailed comments next week to the Centers for Medicare & Medicaid Services (CMS) on the first dual-eligible demonstration in Massachusetts.

Implementation of the Medicaid Emergency Psychiatric Demonstration

The NAPHS Board strongly endorsed the Medicaid Emergency Psychiatric Demonstration, which was authorized in the Affordable Care Act. [On 3/13/12 CMS announced 11 states and the District of Columbia as demonstration sites. See www.cms.gov/apps/media/press_releases.asp.] "This $75 million emergency inpatient psychiatric care demonstration program will provide Medicaid patients equal access to all community inpatient psychiatric services," said NAPHS President/CEO Mark Covall. "It will result in Medicaid patients receiving the right care, at the right time, in the right setting. It will also result in a more efficient and cost-effective psychiatric delivery system. We applaud CMS for taking another critical step on the path to full parity for all Americans."