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Federal Mental Health Parity - Changes to BCBSNC Products and Provider Policies

The Mental Health Parity Addiction and Equity Act (MHPAEA), which became effective October 8, 2009, requires groups that offered mental health/substance abuse (MH/SA) benefits to ensure that financial requirements and treatment limitations for MH/SA benefits were no more restrictive than those for medical benefits.

Interim Final Rules, effective for plan years on or after July 1, 2010, provided additional guidance on the type and level of parity for MH/SA required under a health benefit plan. Such guidance, and resulting changes will apply to the following: underwritten groups (51+), self-funded plans (ASO [Administrative Services Only]), MEWAs (Multiple Employer Welfare Arrangements), the State Health Plan, NC Health Choice, and the Federal Employee Program. Please note that the State Health Plan and other self-funded, nonfederal governmental plans (e.g. self-funded county groups) may opt out. The State Health Plan, NC Health Choice and Federal Employee Program will be re-sponsible for ensuring their own compliance. These changes do not apply to our individual* and Medicare products.

Given the aggressive timeline for complying with the law, the following decisions have been made regarding BCBSNC's benefit designs:

Medical Benefits

For our standard PPO and HMO copay plans with 51 or more employees, we are changing the MH/SA benefit to pay at 100% when services are received at an in-network specialist or outpatient. MH/SA inpatient services will continue to be paid at the current deductible and coinsurance levels.

Pharmacy Benefits

The following pharmacy benefit changes will be made effective on July 1, 2010 (underwritten groups) and at renewal for ASO groups beginning July 1, 2010:

  • Smoking cessation will become a standard offering with no benefit limits; safety and clinical limits will apply.
  • Hypnotics will become a standard offering with no benefit limits; safety and clinical limits will apply.

Prior Review and Certification

For all BCBSNC group products effective on a one-time date, July 1, 2010, BCBSNC will revise the penalty for failure to obtain prior review and certification for in-network, inpatient/outpatient MH/SA services to match the penalty under the medical benefit.

Notice of Change in Prior Review and Certification Policy

Effective September 1, 2010, all in-network providers are required to get prior review and certification for inpatient/outpatient MH/SA services. As of September 1, 2010, 60-days from date of notice, if an in-network provider fails to obtain prior review and certification for inpa-tient/outpatient MH/SA services, the provider will not be reimbursed for these services and is not permitted to seek payment from a Member for these services. This change applies only to services received in North Carolina; penalties for failure to receive review and certification when outside of North Carolina remain the same. In addition, only certain outpatient MH/SA services are subject to prior review. If you have questions about which outpatient MH/SA service require prior review, contact Magellan Behavioral Health.

*Health Care Reform will extend these requirements to individual insurance policies; however, the effective date for this change is unclear.

Prior Review and Certification as a Tool to Endorse Best Practices in Mental Health/Substance Abuse Treatment

Individuals with alcohol and drug disorders are generally viewed as "vulnerable populations." As with other chronic conditions, rates of relapse and treatment recidivism among substance-abusing populations are high. About 40 to 60 percent of patients treated for alcohol or drug dependence subsequently return to active symptoms.1 Over the past 15 years, scientific knowledge has increased substantially regarding the use of effective, evidence-based therapies for treating people with substance use conditions. Furthermore, substance use illness is gaining recognition as a chronic condition that must be managed through long-term, coordinated care management. However, as is true of other areas of health care, the increase in scientific knowledge has not been accompanied by the consistent implementation of proven methods of treatment. Many types of programs are used to treat substance use, and the background and training of the health care workers who provide these treatments vary greatly. 2

The U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration has published treatment improvement protocols to educate providers on best practices when dealing with individuals with alcohol and other substance abuse disorders.3 Multiple clinical practice guidelines endorsed by the American Psychiatric Association are published by the National Guideline Clearinghouse at www.guidelines.gov. Insuring appropriate, quality care with best practices is the intent of prior review and certification for certain treatments covered by BCBSNC for these conditions. The intent is not to decrease access or limit appropriate treatment.

1 Policies for the Treatment of Alcohol and Drug Use Disorders: A RESEARCH AGENDA FOR 2010-2015
Dennis McCarty , Ph.D., Oregon Health & Science University; K. John McConnell, Ph.D., Oregon Health & Science University; Laura A. Schmidt, Ph.D., University of California, San Francisco October 2009
2 National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices-A Consensus Report.
National Quality Forum, 2007 http://www.rwjf.org/files/research/nqrconsensusreport2007.pdf
3 http://kap.samhsa.gov/products/tools/keys/pdfs/KK_43.pdf

Additional Information

For additional information about BCBSNC's changes to BCBSNC products and provider policies in response to the latest guidance on MHPAEA, please contact your regional Network Management representative

Network Management contact information by region:

Charlotte (800) 754-8185 Hickory (877) 889-0002
Greensboro (888) 298-7567 Raleigh (800) 777-1643
Greenville (888) 291-1780 Wilmington (877) 889-0001