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Texas Department of Insurance (TDI)Doug Danzeiser
Regulatory Matters Team of theLife, Accident, and Health Section
January 23, 2012
TIPSSLEADERSHIP SUMMIT
Regulation of Mental Health and Addiction Insurance Coverage
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Overview• Federal Laws Relating to Mental
Health and Addiction• State Laws and Regulations
Relating to Mental Health and Addiction
• Other Federal and State Laws and Regulations Relating to Health Insurance
• What Resources TDI Offers
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PUBLIC LAW
110-343 Paul Wellstone and
Pete Domenici Mental Health Parity and
Addiction Equity Act (MHPAEA)
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OVERVIEW
MHPAEA:
enacted on October 3, 2008
effective for plan years beginning October 3, 2009 (January 1, 2010, for calendar year plans)
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APPLICABILITY
applies to fully insured and self-funded large employer plans (employers with more than 50 employees)
Medicaid managed care plans must comply with MHPAEA
applies only to plans that offer mental health (MH) or substance use disorder (SUD) benefits
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BEFORE MHPAEA
Federal law only addressed parity coverage for MH benefits.
Annual or a lifetime dollar limits for MH benefits could be no lower than those on medical/surgical benefits.
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AFTER MHPAEA
Parity law was extended to include substance use disorder (SUD) benefits.
If offer MH/SUD benefits, “financial requirements” for them can be no more restrictive than the “predominant” financial requirements.
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ESSENTIAL REQUIREMENTS
MHPAEA does not create a federal mandate for MH or SUD benefit coverage.
If a plan offers the coverage, then it must be comparable.
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COMPARABLE COVERAGE
Equivalency of coverage applies to all financial requirements, including:deductibles, copayments,
coinsurance;out-of-pocket expenses; andtreatment limitations, such as:
frequency of treatment, number of visits, days of coverage, and similar limits.
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OUT-OF-NETWORK BENEFITS
If provide out-of network coverage for medical/surgical benefits, must also provide out-of-network coverage for MH/SUD benefits.
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SMALL EMPLOYER EXEMPTION
Small employers with 50 or fewer employees are exempt from the MH/SUD parity requirements.
Any state parity laws continue to apply to small employers, as well as to individual (non-employer) plans.
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PATIENT PROTECTION
AND AFFORDABLE
CARE ACT (PPACA)
PUBLIC LAW
111–148
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PPACA identifies MH/SUD services, including behavioral health treatment as essential health benefits.This means:
carriers have limited ability to place lifetime or annual limits on this coverage
small employer and individual plans sold through exchanges in 2014 will provide this coverage.
More information : www.tdi.texas.gov/consumer/cpmhealthcare.html
PPACA OVERVIEW
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TEXAS LAWS AND REGULATIONS
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MAJOR MEDICAL HEALTH COVERAGE
Employer10.8 million
49%
Individual808 k4%
Medicaid3.4 million
16%
Other Public630 k3%
Uninsured6.2 million
28%
Number of Nonelderly Texans by Health In-surance Status
Employer
Individual
Medicaid
Other Public
Uninsured
Source: Kaiser Family Foundation, StateHealthFacts.org –
2008-2009 Census, CPS, ACS
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MAJOR MEDICAL BY FUNDING SOURCE
Private (Fully In-sured) Coverage
5,741,12229%
Publicly Funded Coverage6473862
33%
Self-Funded Coverage7682878
39%
2009 Texas Insured Population by Funding Source
Private (Fully Insured) Cov-erage
Publicly Funded Coverage
Self-Funded Coverage
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TIP
Look for “TDI” or “DOI”
on insurance cards.
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TEXAS INSURANCE CODECHAPTER 1355
BENEFITS FOR CERTAINMENTAL DISORDERS
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TEXAS LAWS AND REGULATIONS – CH. 1355
Group benefits for certain serious mental illnesses and other disorders:must provide at least 45 days of
inpatient and 60 outpatient visits;
no lifetime limits on the number of days of inpatient treatment or the number of visits for outpatient treatment;
must provide parity with any limitations, deductibles, copayments, and coinsurance as those for physical illness;
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TEXAS LAWS AND REGULATIONS – CH. 1355 -- CONTINUED
Benefits continued:
may not count outpatient visits for medication management against the number of outpatient visits; and
must provide the same coverage for outpatient visits as for physical illness.
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TEXAS LAWS AND REGULATIONS – CH. 1355 -- CONTINUED
Chapter 1355 does not require coverage for the treatment of:
addiction to a controlled substance used in violation of the law
mental illness that results from the use of a controlled substance in violation of the law.
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TEXAS LAWS AND REGULATIONS – CH. 1355 -- CONTINUED
Small employers:
Carriers must offer coverage of serious mental illness to small employers.
Small employers may reject the coverage.
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TEXAS LAWS AND REGULATIONS – CH. 1355 -- CONTINUED
Alternative mental health treatment benefits:
IF coverage of mental or emotional illness or disorder treatment is provided when confined in a hospital, THEN must also provide coverage for treatment in a residential treatment center for children and adolescents or in a crisis stabilization unit;
coverage must be at least as favorable as that provided for treatment in a hospital;
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TEXAS LAWS AND REGULATIONS – CH. 1355 -- CONTINUED
Alternative mental health treatment benefits -- continued:
certain requirements are required for coverage;
same benefit maximums, durational limitations, deductibles, and coinsurance that apply to inpatient psychiatric treatment under the plan; and
two days of treatment is equal to one day of treatment in a hospital or inpatient program.
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TEXAS LAWS AND REGULATIONS – CH. 1355 -- CONTINUED
Psychiatric day treatment facilities:
IF group policy provides coverage for treatment of mental or emotional illness or disorder when confined in a hospital, THEN must provide coverage for treatment in a psychiatric day treatment facility.
no less favorable than hospital coverage subject to the same durational limits,
deductibles, and coinsurance factors. two days of treatment equal to one day of
treatment in a hospital or inpatient program.
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TEXAS LAWS AND REGULATIONS – CH. 1355 -- CONTINUED
Psychiatric day treatment facilities -- continued: Insurer is required to OFFER coverage for
treatment of mental or emotional illness or disorder when confined in a hospital or psychiatric day treatment facility.
Policyholder is entitled to reject coverage. Policyholder may select an alternative
level of benefits if offered by or negotiated with the insurer.
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TEXAS INSURANCE CODECHAPTER 1368
AVAILABILITY OF CHEMICAL DEPENDENCY COVERAGE
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Texas Laws and Regulations – Ch. 1368 -- continued
Availability of chemical dependency coverage:
group health benefit plan must provide coverage for the necessary care and treatment of chemical dependency;
parity required except for dollar and durational limits (which have minimum requirements); and
not required for individual plans.
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Texas Laws and Regulations – Ch. 1368 -- continued
Minimum coverage requirements: Coverage may not be less favorable
than that provided for physical illness.
Coverage is subject to the same durational limits, dollar limits, deductibles, and coinsurance that apply to physical illness.
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Texas Laws and Regulations – Ch. 1368 -- continued
Availability of chemical dependency coverage -- continued:
Required coverage is limited to a lifetime maximum of three separate treatment series for each covered individual.
Coverage for necessary care and treatment in a chemical dependency treatment center must be provided as if the care and treatment were provided in a hospital.
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TITLE 28 TEXAS ADMINISTRATIVE
CODECHAPTER 21
SUBCHAPTER PSECTIONS 21.2401 –
21.2407
MENTAL HEALTH PARITY
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Texas Laws and Regulations -- continued
The TDI parity rules –were adopted February 9, 2011,
for plans issued after March 1, 2011
enable TDI to maintain state regulatory authority
apply to serious mental health and substance use disorder benefits.
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TITLE 28 TEXAS ADMINISTRATIVE
CODECHAPTER 3
SUBCHAPTER HHSECTIONS 3.8001 – 3.8030
STANDARDS FOR REASONABLE COST
CONTROL AND UTILIZATION REVIEW FOR CHEMICAL
DEPENDENCY TREATMENT CENTERS
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Texas Laws and Regulations -- continued
Implements the legislative requirement in section 1368.007 of the Insurance Code that TDI adopt guidelines for reasonable cost controls and utilization review of chemical dependency treatment.
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Texas Laws and Regulations -- continued
For various levels of care (inpatient to outpatient), the rule addresses criteria for:
admissioncontinued staylength of stay, and discharge.
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TEXAS INSURANCE CODECHAPTER 1355
PROMPT PAY
DEPARTMENT OF INSURANCE
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PROMPT PAY LAWSAPPLICABILITY
Applicable to Accident and Health:• health maintenance organizations (HMOs)• insured PPO plans
Not applicable to:• self-funded ERISA plans• indemnity plans• Medicaid, Medicare, and Medicare Supplement• self-funded government and school plans• Children’s Health Insurance Program (CHIP), or• plans issued in other states.
Texas Laws and Regulations -- continued
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APPLICATION TO PROVIDERS
Contracted providers under HMO plans, insured PPO plans
Non-contracted providers of emergency and referral services
Prompt Pay Laws - Continued
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PREAUTHORIZATION disclosure of services for which
preauthorization is required once preauthorized, carrier may not deny or
reduce payment based on medical necessity or appropriateness of care
response deadlines• life-threatening condition or post-
stabilization - one hour• concurrent hospitalization - 24 hours• all other requests - three calendar days.
Prompt Pay Laws - Continued
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ELIGIBILITY INQUIRIES AND VERIFICATION REQUESTS
eligibility inquiry• not a guarantee of payment
verification• guarantee of payment: “cannot reduce
or deny payment”• exceptions: misrepresentation and
failure to perform• response deadlines without delay, not
to exceed:olife-threatening condition or post-
stabilization - one houroconcurrent hospitalization - 24
hoursoall other requests - five calendar
days.
Prompt Pay Laws - Continued
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MORE INFORMATION
www.tdi.texas.gov/hprovider/ppsb418faq.html
Prompt Pay Laws - Continued
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The Texas Department of Insurance
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THE COMPLAINT PROCESS
DEPARTMENT OF INSURANCE
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PROVIDER OMBUDSMANresponds to inquiries from
providers and carriers regarding the prompt payment of claims laws and regulations.
monitors complaint trends among carriers and across issues
email: [email protected]
DEPARTMENT OF INSURANCE
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COMPLAINT PROCESSING
1. receive complaintphone callwritten, including online form, e-
mail, fax, or letteranonymous
2. prioritize complaints according to nature, severity, and industry impact; appropriately note confidential information
DEPARTMENT OF INSURANCE
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COMPLAINT PROCESSING, CONTINUED
3. prepare response to correspondence• send acknowledgement to customer • write to regulated entity, include
complaint• entity must respond in 10 days or
request an extension • review responses from regulated
entity• complete legal research and obtain
additional necessary information
DEPARTMENT OF INSURANCE
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COMPLAINT PROCESSING, CONTINUED
4. screen issues for referral: identify “frivolous,” justified, and unjustified
complaints check for potential enforcement, fraud, or
market conduct referrals; and check for consumer education issues.
5. send response to customer mail, fax, or e-mail response with
informational/educational content copy the carrier or other entity complained
about on TDI’s closing letter (as appropriate) average processing time is 30 days.
DEPARTMENT OF INSURANCE
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THE ENFORCEMENT PROCESS
DEPARTMENT OF INSURANCE
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HOW TDI LEARNS OF VIOLATIONS
complaints• providers• consumers• agent• company• anonymous
internal discovery• examination• failure to file• failure to
respond to TDI inquiry
other regulatory agency
law enforcement
DEPARTMENT OF INSURANCE
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METHODS OF INVESTIGATION
written inquiryon site examinationsubpoenawitness statementsundercover
DEPARTMENT OF INSURANCE
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ENFORCEMENT ACTIONS
TDI may seek:revocation of license or
authorizationfinerestitutioncorrective actioncease and desist order
DEPARTMENT OF INSURANCE
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POSSIBLE ENFORCEMENT OUTCOMES
informal resolution with or without a consent order
contested case resolutionemergency cease and desist
orderreferral to Texas Attorney General
DEPARTMENT OF INSURANCE
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WHAT CAN YOU DO?
review your contractscomplain to TDIprovide copies of
correspondence between you and the insurer
provide other documentation supporting your complaint
DEPARTMENT OF INSURANCE
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INSURANCE FRAUD
DEPARTMENT OF INSURANCE
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TDI’s Fraud Unit investigates insurance fraud for referral to
state and federal prosecutors employs certified peace officers, prosecutors,
certified fraud examiners, certified internal auditors, and criminal analysts
coordinates investigations with other agencies
interviews suspects and witnesses analyzes financial, business, and legal
documents documents the flow of money transactions prepares investigative reports for prosecutors
DEPARTMENT OF INSURANCE
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Reporting Fraud
Report insurancefraud by calling
1-888-327-8818Insurance Fraud Hotline
Online reporting available at:www.tdi.texas.gov
Follow link to “Insurance Fraud”
DEPARTMENT OF INSURANCE
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EMERGING ISSUES
DEPARTMENT OF INSURANCE
federal health reform• guaranteed issue/individual mandate• premium support and Medicaid expansion• exchanges and essential health benefits• risk adjustment
limited networks• exclusive provider plans• accountable care organizations• health care collaboratives• tiered networks
preferred provider plan rules decline of commercial HMO enrollment
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HELPFUL RESOURCES
TDI Website: www.tdi.texas.gov Consumer Protection Help Line:
800-252-3439
Consumer Protection: [email protected]
Doug Danzeiser: [email protected],
512-475-1964
DEPARTMENT OF INSURANCE