Massachusetts Regulations

Minuteman Health submitted comments (pdf | Get Adobe® Reader®) to the Massachusetts Division of Insurance (DOI) on DOI’s review of all existing regulation. Minuteman Health requested the following changes to the Enforcement of Mental Health Parity regulation issued by DOI in 2013:

• Removal of the requirement that health insurers demonstrate compliance with regulations, guidelines, sub-regulatory guidance, or related instructions on the Federal Parity Law
• Removal of the requirement that the chief executive officer sign the certification that the health insurer is in compliance with state and federal parity laws
• Addition of a line stating that the suspension or revocation of a health insurer’s license is only permissible if the health insurer violated federal or state parity laws intentionally

Tufts Associated Health Maintenance Organization (HMO), Inc. submitted comments (pdf | Get Adobe® Reader®) to the Massachusetts Division of Insurance (DOI) on the review by DOI of all existing regulation. Tufts Associated HMO recommended that DOI extend the certification process defined within the 2013 bulletin detailed below to managed care organizations. Currently, managed care organizations must complete a checklist (pdf | Get Adobe® Reader®) that requires plans to certify that they are in compliance with federal and state parity laws.

Former Massachusetts Attorney General, Martha Coakley, signified in a letter (pdf | Get Adobe® Reader®) and presentation (pdf | Get Adobe® Reader®) to the state Health Policy Commission (HPC) that achieving parity was an important priority to her office:

“Today before the Commission, our office focuses on behavioral health in the Commonwealth. For many patients behavioral health treatment is just as essential as physical health treatment. The law provides for mental health parity. I am deeply committed to making true parity not just an aspiration but a reality. On the cost front, behavioral health may reflect a small portion of overall spending, but given the documented high cost of spending for individuals with comorbid behavioral health and medical conditions, how we invest our behavioral health dollars has enormous potential for impacting overall health care spending. Real mental health parity is not only a matter of good health care policy but also a matter of social justice. It will require a sustained and broad-based commitment well beyond today’s hearing, as both I and the HPC understand well.”

This level of attention from a state’s attorney general is an important step towards increasing compliance with parity laws.

The Massachusetts Division of Insurance (DOI) contracted (pdf | Get Adobe® Reader®) Dixon Hughes Goodman LLP to examine insurance companies’ utilization management records for two different groups of patients who had received emergency department treatment and then needed follow-up care. One group was patients who needed behavioral health (BH) treatment and the other group was patients who needed non-behavioral health (NBH) treatment. The purpose of the examination was to see if there were differences in how the insurance companies reviewed and authorized treatment decisions for the BH patients compared to the NBH patients.

The examination found that BH Patients on average have to wait much longer for follow-up care than NBH patients, although the delays were not necessarily caused by federal or state parity law violations. Dixon Hughes Goodman did not conclude that parity violations definitely took place, but noted that records were lacking details for many of the patients who had to wait more than 24 hours for follow-up care.

The report recommended, among other things, that the DOI should create standards for the detail required in insurance company records about follow-up care so that it is easier to see if there are differences in the utilization management process for BH patients versus NBH patients. The report also recommended that the DOI strengthen its Federal Parity Law certification process to collect more information about any possible differences insurance companies have in their review processes for BH patients compared to NBH patients.

This examination by the DOI is encouraging because it demonstrates that the department is taking concrete steps to ensure parity compliance.

The Massachusetts Division of Insurance (DOI) issued a bulletin clarifying requirements under Federal and state mental health parity laws. The report clarifies that health insurers must provide all enrollees information on their rights under parity laws and how to file a complaint. It also summarizes the following information health plans must submit for state certification:

• A certification to DOI stating that they completed a comprehensive review for compliance with parity laws
• An explanation of any differences in the processes used to develop mental health and substance use disorder criteria vs. medical and surgical criteria
• An explanation of any differences in how mental health and substance use disorder providers vs. medical and surgical providers are notified about medical necessity criteria
• An explanation of any differences in the processes mental health and substance use disorder providers vs. medical and surgical providers must follow to request authorization for a service
• An analysis of how plans meet the federal parity law standards if there is a difference between the processes, standards and criteria applied to mental health and substance use disorder services vs. medical and surgical services
• An explanation of any difference in the standards for granting authorization of out-of-network services for mental health and substance use disorder services vs. medical and surgical services
• A list of any differences in cost-sharing or benefit limitations for mental health and substance use disorder services vs. medical and surgical services

The carrier must also submit the following data:

• Number of times patients/providers requested authorization for services
• Number of services requested (e.g., inpatient days or outpatient visits)
• Number of requests authorized
• Number of requests modified
• Number of requests denied
• Number of reduced or denied requests appealed through the internal appeals process
• Number of internally appealed requests approved
• Number of internally appealed requests denied
• Number of internally appealed requests sent for external appeal
• Number of externally appealed adverse determinations overturned
• Number of externally appealed adverse determinations upheld

The bulletin also explains that complaints concerning Mental Health Parity Laws can be submitted to DOI verbally or in writing.

The Massachusetts Division of Insurance (DOI) issued a bulletin regarding the impact of the Affordable Care Act and newly required essential health benefits for individual plans and small employer fully-insured plans. The bulletin explained that these plans are now required to cover services for all behavioral health conditions “on a non-discriminatory basis.” It specified that treatment limitations could not be “more restrictive” for behavioral health coverage than what is in place for other medical coverage.

The Massachusetts Division of Insurance (DOI) held a hearing on the 2013 promulgation of the two mental health parity regulations explained below.

In 2013, the Massachusetts Division of Insurance issued a regulation (pdf | Get Adobe® Reader®) regarding parity compliance. These regulations require insurance plans to submit materials showing how they will meet the standards in the Massachusetts Parity Law (law found below.) The Division also issued a bulletin to insurance plans notifying them of the requirements of the regulation.

Plans had to submit their initial certification materials by October 1, 2013. Plans had to review their practices as well as those of the organizations they subcontract with, for compliance with the Massachusetts Parity Law and the Federal Parity Law .

Plans had to submit documents to the Division of Insurance and the Office of the Attorney General showing that the plan had done a full review of their practices for compliance with the Massachusetts Parity Law and the federal law. The documents had to be signed by the plan’s chief executive officer (CEO) and chief medical officer (CMO).

Plans are required to review their practices every year. By July 1st every year, plans have to submit documents to the Division of Insurance and the Office of the Attorney General showing that the plan had done a full review of their practices for compliance with the Massachusetts Parity Law and the federal law. The documents had to be signed by the plan’s chief executive officer (CEO) and chief medical officer (CMO).

Complaints against insurance plans for noncompliance with the Massachusetts Parity Law and/or the federal law can be presented verbally or in writing to the Division of Insurance.

Plans must give all of the people currently covered by the plan a written notice which explains the covered person’s rights under the Massachusetts Parity Law and the federal law.

Complaints made against plans will be reviewed by the Insurance Commissioner. The Insurance Commissioner can investigate a plan at any time.

The Insurance Commissioner can examine and review any plan at any time when the Insurance Commissioner believes the plan is being noncompliant.

The Insurance Commissioner can give one or more of the following penalties against plans if the Insurance Commissioner finds a parity violation or noncompliance.

1. A corrective action plan and a timeframe to achieve compliance
2. 
A civil fine up to $10,000 for each violation
3. Suspension or revocation of a plan’s accreditation
4. Suspension or revocation of a plan’s license or certificate of authority

The Massachusetts Office of Medicaid issued a regulation (pdf | Get Adobe® Reader®) that addressed parity, among other things. On the final page of the linked regulation it explains that Medicaid managed care organizations (MCOs), senior care organizations, and integrated care organizations must all comply with the Federal Parity Law. MCOs must submit certification every year stating that their plans meet the requirements of the state parity laws and the Federal Parity Law. If their plans are not in compliance with parity laws, the certification must say so and describe how the plan(s) will become compliant. A member enrolled in any of these plans can file a grievance with MassHealth if they experience a parity violation.

The Massachusetts Division of Insurance (DOI) issued a bulletin regarding mandated coverage for the treatment of autism spectrum disorder within fully insured health plans. The bulletin highlights that health insurers can not limit coverage for the diagnosis and treatment of autism to a fixed number of visits or days or require that visits be completed within a defined period.

The Massachusetts Division of Insurance (DOI) issued a bulletin highlighting new provisions in state law requiring plans to cover services relating to the diagnosis and treatment of autism spectrum disorder. The bulletin defines autism service provider. It also defines adequate access of ASD services as the following:

• At a minimum, at least two certified behavior analysts
• Access to all mandated ASD services including, but not limited to, applied behavior analysis
• A sufficient number of providers to provide access to all medically necessary habilitative and rehabilitative services for ASD

The bulletin also states that if these services are not available, the health insurers must arrange for out-of-network services.

The Massachusetts Division of Insurance (DOI) issued a bulletin notifying plans that a bill passed in 2008 changed the state parity law so that eating disorders, substance use disorders, post-traumatic stress disorder, and autism are now on the list of “biologically-based mental disorders.”

The bulletin also explained that the Federal Parity Law requires plans to have similar annual limits, lifetime limits, financial requirements, and other treatment limitations for behavioral health services as they have for other medical services. It also states that plans cannot require that behavioral health services be available only from in-network providers.