CO's Medicaid Mental Health Alternative Services  

This is really where the rubber meets the road on Medicaid & Parity:  these "Medicaid Mental Health Alternative Services."

If designation of a Medicaid Mental Alternative Service in and of itself is allowed to defeat Parity -- what is the point in having Medicaid Parity in the first place?
CMS Parity Compliance Toolkit
2.2 Key Steps in the Parity Analysis Process

The key steps in the parity analysis process are as follows:
  1. Identify all benefit packages to which parity applies (including all benefits provided to MCO enrollees, regardless of authority, and benefits in FFS ABP and separate CHIPs). A benefit package includes all benefits provided to a specific population group (e.g., children, adults, individuals with a nursing facility level of care) regardless of delivery system.
  2. For each benefit package, determine whether the state or an MCO is responsible for the parity analysis. If an MCO is responsible for the parity analysis, the state should ensure that the MCO contract includes applicable requirements for the MCO to perform the parity analysis.
  3. Determine which covered benefits are MH/SUD benefits and which are M/S benefits (see section 3 of this Toolkit).
  4. Define the four benefit classifications (inpatient, outpatient, prescription drugs, and emergency care) and determine into which benefit classification MH/SUD and M/S benefits fall (see section 4 of this Toolkit).
  5. Identify and test each AL/ADL applied to MH/SUD benefits for compliance with applicable parity requirements (see section 5 of this Toolkit).
  6. Identify and test each FR and QTL applied to MH/SUD benefits in a classification, by benefit package, for compliance with applicable parity requirements (see section 5 of this Toolkit).
  7. Identify and test each NQTL applied to MH/SUD benefits in a classification, by benefit package, for compliance with applicable parity requirements (see section 6 of this Toolkit).
  8. Assess compliance with requirements regarding availability of information (see section 9 of this Toolkit).
  9. On the state’s website, document and post findings from the parity analysis, including any follow-up activities, applicable to the benefits provided to enrollees of MCOs.
  10. Implement any changes needed to the Medicaid state plan, ABP state plan, child health plan, MCO/PIHP/PAHP contract, MCO/PIHP/PAHP rates, state policies and procedures, MCO/PIHP/PAHP policies and procedures, and so forth, in order to meet parity requirements by the applicable compliance date.  
Colorado's "Alternative Services" for Community Behavioral Health
​
8.212.4.B. Alternative services of the Community Behavioral Health Services program are:

1. Vocational -- Services designed to help adult and adolescent clients who are ineligible for state vocational rehabilitation services to gain employment skills and employment. Services are skill and support development interventions, educational services, vocational assessment, and job coaching.

2. Assertive Community Treatment (ACT) – Comprehensive, locally-based, individualized treatment for adults with serious behavioral health disorders, that is available 24 hours a day, 365 days a year.

Services include case management, initial and ongoing behavioral health assessment, psychiatric services, employment and housing assistance, family support and education, and substance use disorders services.

3. Intensive Case Management -- Community-based services averaging more than one hour per week, provided to adults with serious behavioral health disorders who are at risk of a more intensive 24 hour placement and who need extra support to live in the community.

Services are assessment, care plan development, multi-system referrals, assistance with wraparound and supportive living services, monitoring and follow-up. Intensive case management may be provided to children/youth under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

4. Clubhouse and drop-in center services – Peer support services for people who have behavioral health disorders, provided in a Clubhouse or Drop-In Center setting.

Clubhouse participants may use their skills for clerical work, data input, meal preparation, providing resource information and outreach to clients. Drop-in Centers offer planned activities and opportunities for individuals to interact socially, promoting and supporting recovery.

5. Recovery Services – Community-based services that promote self-management of behavioral health symptoms, relapse prevention, treatment choices, mutual support, enrichment, rights protection, social supports.

Services are peer counseling and support services, peer-run drop-in centers, peer-run employment services, peer mentoring, consumer and family support groups, warm lines, and advocacy services. CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.200 Medical Services Board 71

6. Residential Services – Twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, appropriate for adults whose mental health issues and symptoms are severe enough to require a 24-hour structured program but do not require hospitalization.

Services are provided in the setting where the client is living, in real-time, with immediate interventions available as needed.

Clinical interventions are assessment and monitoring of mental and physical health status; assessment and monitoring of safety; assessment of/support for motivation for treatment; assessment of ability to provide for daily living needs; observation and assessment of group interactions; individual , group and family therapy; medication management; and behavioral interventions.

Residential services may be provided to children/youth under EPSDT.

7. Prevention/Early Intervention Services – Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health.

Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.

8. Respite Care – Temporary or short-term care of a child, youth or adult client provided by adults other than the birth parents, foster/adoptive parents, family members or caregivers that the client normally resides with.

Respite is designed to give the caregivers some time away from the client to allow them to emotionally recharge and become better prepared to handle normal day-to-day challenges. Respite care providers are specially trained to serve individuals with behavioral health issues.

We Heard Back from the State on Parity. 

We Would Like Additional Discussions with the State Before We Decide To Contact CMS Region 8 on What We Believe is Colorado Medicaid's Failure to Comply with Parity

Our Original Letter to the State re: Parity & Assertive Community Treatment.



Our Initial Response Back to the State

​Hi Gretchen -- Thanks so much for the response.  It was really helpful.

I'll look into the resources you mentioned.  If there is something out that is better and cheaper, I'm not going to argue for something that is more expensive and less effective.

I think my take right now is that ACT is covered with regard to financial requirements or treatment limitations -- otherwise the whole non-qualitative [this should probably be non-quantative] [treatment limitation concept within parity becomes meaningless.  Now maybe that's not going to be the majority view and this is all still pretty new.


42 CFR 438.920
(c) Scope. This subpart does not -

(1) Require a MCO, PIHP, or PAHP to provide any mental health benefits or substance use disorder benefits beyond what is specified in its contract, and the provision of benefits by a MCO, PIHP, or PAHP for one or more mental health conditions or substance use disorders does not require the MCO, PIHP or PAHP to provide benefits for any other mental health condition or substance use disorder;

(2) Require a MCO, PIHP, or PAHP that provides coverage for mental health or substance use disorder benefits only to the extent required under 1905(a)(4)(D) of the Act to provide additional mental health or substance use disorder benefits in any classification in accordance with this section; or

(3) Affect the terms and conditions relating to the amount, duration, or scope of mental health or substance use disorder benefits under the Medicaid MCO, PIHP, or PAHP contract except as specifically provided in §§ 438.905 and 438.910.


42 CFR 438.905 - Parity requirements for aggregate lifetime and annual dollar limits.
42 CFR 438.910 Parity requirements for financial requirements and treatment limitations.

I'll look at the resources and get back with you.

Thanks so much for your courtesy,

Val



​See Also:​
​The final rule requires that all beneficiaries who receive services through managed care organizations, alternative benefit plans, or CHIP be provided access to mental health and substance use disorder benefits that comply with parity standards, regardless of whether these services are provided through the managed care organization or another service delivery system.

States are required to include contract provisions requiring compliance with parity standards in all applicable contracts for these Medicaid managed care arrangements that provide services to enrollees in managed care organizations, including prepaid inpatient health plans or prepaid ambulatory health plans.

In contrast to the proposed rule, this final rule also extends parity protections to apply to long term care services for mental health and substance use disorders in the same manner that they are applied to other services.

Key Provisions for Medicaid Managed Care Organizations Under the final rule, states that have contracts with managed care organizations are required to meet the parity requirements regarding financial and treatment limitations consistent with the regulation applicable to private insurers.

States will include the cost of providing additional services or removing treatment limitations in their capitation rate methodology for affected managed care plans. 

By allowing changes to the managed care rate setting process, the rule also provides each state with flexibility to enable Medicaid managed care organizations to fully comply with the rule by including additional costs necessary to include extra services or remove treatment limits without changing the state’s non-alternative benefit plans and state plan.

​ In addition, the final rule requires managed care entities to make available upon request to beneficiaries and contracting providers the criteria for medical necessity determinations with respect to mental health and substance use disorder benefits.

The rule also directs managed care plans to make available to the enrollee the reason for any denial of reimbursement or payment for services with respect to mental health and substance use disorder benefits.
Response from the State

Hello Val,
 
Thank you for reaching out to us about Mental Health Parity and Assertive Community Treatment.
 
As I shared with you earlier this week, the Department has posted our Parity Analysis Report on our website.  We also recently recorded a webinar and published a Frequently Asked Question document.  You can find these updated resources here: https://www.colorado.gov/hcpf/regulatory-resource-center
 
I also wanted to make you aware of another statewide resource from the Governor’s Office called Results First.  This process uses rigorous analysis to catalog state programs and explore the cost-benefit of the programs based on evidence.  Over the last year there have been reports done on programs that serve individuals involved in the criminal justice system and some of the behavioral health programs managed by the Department of Human Services, including ACT.   All of the reports published to date are listed here: https://sites.google.com/state.co.us/rfpfs/colorado-results-first/reports?authuser=0
 
The goal of Parity is to ensure Medicaid members have similar access to mental health and substance use disorder benefits as they do to medical and surgical benefits. Assertive Community Treatment (ACT) delivered to Medicaid enrolled individuals is a service provided through contracts with the Behavioral Health Organizations (BHOs) and is available to members with a BHO covered diagnosis.

​Although, the final Parity rule does not require managed care entities to provide mental health and substance abuse services beyond the scope of its contract nor require managed care entities to cover any specific mental health or substance abuse benefit (42 CFR part 438.920), we continue to work with the Behavioral Health Organizations to ensure access to ACT when appropriate for the member.
 
As the Results First studies show, there are also a number of other effective services that have been proven to support individuals with behavioral health needs and those involved in the criminal justice system. 
 
We appreciate your ongoing interest in making sure individuals in Colorado with behavioral health needs are well served.
 
Gretchen
 
Gretchen M. Hammer
Medicaid Director
Colorado Department of Health Care Policy and Financing​





















We have quoted from the CMS document below.  The quote is to the left.

Mass. Ass. Of Mental Health:  Comments on Parity

 If Parity doesn't cover Assertive Community Treatment under Medicaid -- who are we really fooling & hurting?

"For example, all insurers cover inpatient mental services and crisis stabilization, but only Medicaid covers Programs of Assertive Community Treatment (PACT), considered by many experts to be a critical component of a comprehensive community mental health system and a significant safeguard against institutionalization."

Massachusetts Association for Mental Health 
electronic mail to parity@hhs.gov
Laurel Fuller
ASPE
200 Independence Ave. SW Room 424E
Washington, DC 20201
Re: Strategies for Improving Parity for Mental Health and Substance Use Disorder Coverage

Dear Ms. Fuller:

Since 1913, the non-profit Massachusetts Association for Mental Health (MAMH) has been a leading voice for the creation of services for people with mental illness. The National Institute of Mental Health (NIMH) has designated MAMH as its Massachusetts partner for the dissemination of science based information about mental illness. MAMH led the successful effort to enact Massachusetts’ comprehensive mental health parity in insurance coverage legislation in 2000 and was a principal partner in achieving legislation in 2008 to broaden the law’s mandate.

MAMH continues to fight for implementation of State and Federal parity laws, regulations, and policies. It is an active partner in the Massachusetts Mental Health Parity Coalition, a group of provider and consumer advocacy organizations committed to making mental health and substance use disorder parity a reality.

We welcome the opportunity to provide written public comment on improved Federal and State coordination related to section 2726 of the Public Health Services Act, section 712 of the Employee Retirement Income Security Act of 1974, and section 9812 of the Internal Revenue Code of 1986 and related sections of State law.

The Massachusetts Parity Law.Parity requirements were first established in 2000 by An Act Relative to Mental Health Benefits, Chapter 80 of the Acts of 2000 (Chapter 80), and significantly amended in 2008 by Chapter 256 of the Acts of 2008 (Chapter 256).1 Together Chapters 80 and 256 are commonly known as the “Massachusetts Parity Law” and are widely recognized to be among the Nation’s most comprehensive State parity statutes.

The Massachusetts Commissioner of Insurance has the authority to implement and enforce both Federal and State parity laws. Mass. General Laws, chapter 26, section 8K.

The Massachusetts and Federal parity laws and the Affordable Care Act (ACA) complement each other.2 For example, the Federal parity law applies to some kinds of plans not covered by the Massachusetts law (e.g., large group, self-insured plans and some Medicaid plans).

However, unlike the Federal parity law, the State law requires affected health plans to include a full range of mental health mental health benefits for a 13 biologically-based mental health conditions. Small group and individual plans are covered by the ACA and mental health and substance use disorder treatments are among ACA’s essential health benefits.

Problems we have identified.
Despite the Federal and Massachusetts statutes, and some creative implementation and monitoring by our State regulators,3 enforcement and implementation here has been less successful than we have hoped. The experience here seems to mirror that elsewhere in the Nation.

We have noted several problems.4 First, many consumers and policy holders we have talked with have the impression that although a plan may appear to be in compliance, denials of coverage for mental health services are in fact more common than for other conditions.

This may be a consequence of non-quantitative treatment limitations (NQTL) like “fail first” policies (particularly for medication) or more stringent medical necessity criteria. A national online survey of admittedly anecdotal evidence by the National Alliance on Mental Illness (NAMI) indicated that mental health patients were twice as likely to be denied coverage for care on medical necessity grounds as for other conditions.5 

Second, it is our experience that the complex enforcement mechanisms discourage patients from complaining about denials of coverage or policy terms. Although government agencies, insurers, and advocacy organizations all make informational materials available in print and online, it is very difficult to simplify the complicated enforcement structure. DOL, HHS, State insurance commissioners, and State Medicaid agencies each have an enforcement role, usually depending on how and where the person is insured.

And, according to a recent Health Policy Brief, State officials do not agree on the extent of their authority to enforce Federal law.6 There is no single, specific, simple source for information about how to complain about denial of coverage.

Third, many people who reach out to MAMH complain that they cannot access mental health or substance use services. While this problem may be related in part to need and demand outstripping the availability of some services, we have also concluded that some of the problem is caused by the difficulties finding an in-network provider.7 

Low rates of reimbursement may account at least in part for the apparent shortage of mental health practitioners who accept insurance.

Moreover, a survey in 2017 by the Massachusetts Department of Insurance (DOI) demonstrates the wide variances in coverage provided by HMOs and insurance companies, particularly when compared to the Medicaid program.

For example, all insurers cover inpatient mental services and crisis stabilization, but only Medicaid covers Programs of Assertive Community Treatment (PACT), considered by many experts to be a critical component of a comprehensive community mental health system and a significant safeguard against institutionalization.8

Our recommendations.
  1. The single most important objective for the Federal government should be vigorous enforcement and oversight of the parity laws. The federal government should encourage rigorous State enforcement and should step in when the State cannot or will not enforce the parity law.
  2. Consumers and patients must have access to clear, simple and understandable information.
  3. States and the Federal government should work together to insure, for example,
  4. that Policies and informational materials clearly disclose what is covered;9

    • Insurers provide up to date and comprehensive lists of eligible network providers;
    • Appeal and grievance process and timelines are clearly presented; and,
    • Criteria for denial, particularly when based on non-quantitative treatment limitations (NQTL) like prior authorization, utilization review, or fail first polices, are clearly explained.
Thank you for the opportunity to comment. Sincerely,
Danna Mauch, PhD President and CEO
CC: Attorney Robert Fleischner, MAMH Board Member
CC: Ambassador (Ret) Barry White, MAMH Board Chair