New Hampshire – Market Conduct Exams Identify Deficiencies with Anthem and Harvard Pilgrim Parity Compliance (Feb 2020)

In 2017, the New Hampshire Insurance Department started market conduct examinations of Anthem, Ambetter by NH Healthy Families, and Harvard Pilgrim.  The regulatory review reflects an 18-month look at the health plans’ adherence to the Federal Parity Law during the exam period of January 2016 to July 2017.

In several examination reports published in early 2020,  the Department found that Anthem and Harvard Pilgrim had a number of problems associated with the offering and reimbursement for MH/SUD treatments.  In particular, the state observed that both health plans are reimbursing providers for mental health services at lower rates than they do for other medical treatments.  The findings stop short of accusing the health plans from violating the Federal Parity Law. The reports represent a warning sign and it puts an obligation on the carrier to come forward with documentation about what their procedures and standards are for setting reimbursement rates.  The health plans disagreed with the findings.

The state is requiring Anthem and Harvard Pilgrim to demonstrate comparable provider reimbursement practices as written and in operation. The health plans shall:

  • Develop, in writing, an analytic framework describing its provider reimbursement practices. For example, the health plans need to demonstrate a framework that is sufficiently objective and verifiable through quantitative metrics that   can be used to demonstrate   their respective processes, strategies, evidentiary standards and other factors for provider reimbursement are comparable and that they do not apply them more stringently to MH/SUD services.
  • Utilize this framework (1) to re-evaluate its MH/SUD statewide fee schedules at the beginning of the monitoring period and (2) to review its MH/SUD statewide fee schedules annually thereafter. In doing so, the health plans shall make such adjustments to their respective schedules as are warranted by the conscientious application of this framework.
  • If the health plans use custom fee schedules for certain providers or provider groups that depart from the statewide fee schedules, the framework shall explain how the processes and factors relied upon in establishing that variation from the statewide fee schedule are consistent with the Federal Parity Law’s comparability requirements and whether the applicable health plan is applying its processes, strategies, evidentiary standards and other factors for determining reimbursement rates more stringently to MH/SUD services by acting in a manner that is arbitrary or discriminatory.

The state is also requiring the health plans implement and adhere to the written plan to ensure that each health plans is taking steps to develop a MH/SUD network that is comparable to the steps it takes to develop a M/S network, factoring in patients’ needs. The health plans must continue to undertake efforts to capture and understand MH/SUD treatment needs of at-risk populations and work to address those needs. The requirement to take steps to develop its MH/SUD network that are comparable to the steps it takes to develop  its M/S network shall not be interpreted to require the Company to achieve comparable results, as there may be exogenous factors beyond the Company’s control that contribute to disparate outcomes.

Other minor violations were identified in the market conduct exam reports regarding specific ways the policies were designed and payments were made. Anthem and Harvard Pilgrim contested the report findings but will comply with the corrective action plan put forth by the state.  The health plans will provide quarterly reports back to the states for two years.  Other follow-up actions are outlined if the health plans fail to meet the conditions of the settlement agreements.

In a third review against Ambetter by NH Health Families, the state found a number   of MH/SUD violations regarding prior authorization, appeals, how claims were paid processed, financial/quantitative treatment limitations (QTLs) comparability analysis requirements, failure to include some benefits (such as treatment for injuries due to self-harm), some network adequacy issues, balance billing, etc.  The health plan agreed to a corrective action plan to be submitted within 60 days with follow-up from the state with a targeted market conduct exam.

No financial fines appeared to be assessed against the three health plans.

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