Parity implementation compliance questions
Download as DOC, PDF0 likes103 views
The document contains a series of questions for a state regarding compliance with parity regulations for Medicaid and private managed care organizations (MCOs) that provide both medical and mental health/substance use disorder benefits. It asks whether MCOs in the state impose quantitative treatment limits or fail to reimburse for certain mental health/substance use disorder treatments. It also asks if MCOs apply inequitable non-quantitative treatment limitations to physical and mental health services. Responses should be sent to Rebecca Farley at the National Council.
Parity implementation compliance questions
- 1. Parity Implementation Compliance Questions Please send your responses to Rebecca Farley at the National Council (RebeccaF@thenationalcouncil.org). Thank you! 1. Do any of the Medicaid or private Managed Care Organizations (MCOs) in your state offer medical benefits AND at least one of the following mental health and/or addiction benefits? In-patient, in-network: Benefits furnished on an inpatient basis and within a network of providers established or recognized under a plan. Inpatient, out-of-network: Benefits furnished on an inpatient basis and outside any network of providers established or recognized under a plan. This classification includes inpatient benefits under a plan that has no network of providers. Outpatient, in-network: Benefits furnished on an outpatient basis and within a network of providers established or recognized under a plan. Outpatient, out-of-network: Benefits furnished on an outpatient basis and outside any network of providers established or recognized under a plan. This classification includes outpatient benefits under a plan that has no network of providers. Emergency care: Benefits for emergency care. Prescription drugs: Benefits for prescription drugs. Note: If you answered ‘Yes’, then these MCOs are subject to the regulations. Please continue to Question #2. If you answered ‘No’ to this question (i.e. the MCO provides only medical or only MH/SUD benefits), then the MCO under question is not subject to these regulations. 2. Are you aware of any Medicaid or private MCOs that are currently applying arbitrary quantitative treatment limits (e.g. annual or lifetime limits) on inpatient or outpatient MH/SUDs services? If so, please provide the name of the MCO, types of benefits covered, treatment limitations applied, and source of your information. 1
- 2. 3. Are any of the Medicaid or private MCOs in your state not reimbursing for certain MH/SUDs treatments or treatment categories? Examples of applicable services include: residential, ACT, psychosocial rehabilitation, crisis intervention) If so, please provide the name of the MCO, State, treatments not reimbursed, and source of your information. 4. Are these MCOs applying inequitable non-quantitative treatment limitations** (NQTLs) to physical health and MH/SUD services? If so, please provide the name of the MCO, State, treatments not reimbursed, and source of your information. ** Examples of NQTLs include: (A) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (B) Formulary design for prescription drugs; (C) Standards for provider admission to participate in a network, including reimbursement rates; (D) Plan methods for determining usual, customary, and reasonable charges; (E) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policy or step therapy protocols); and (F) Exclusions based on failure to complete a course of treatment. 2