Medicaid Parity

Millions of Americans face the problem of not having adequate insurance protection against the costs of treatment, even for those participating in a Medicaid program. After a great deal of advocacy efforts, rules have been published that results in the states having to comply with federal parity laws, in particular the Mental Health Parity and Addiction Equity Act of 2008. This is an important step forward in ensuring mental health parity for individuals living with a mental health condition or substance use disorder (MH/SUD).

Mental Health Parity and Addiction Equity Act

The Mental Health Parity and Addiction Equity Act (MHPAEA) makes it easier for those individuals participating in a Medicaid program to get the care they need. It does this by putting an end to discriminatory practices that limit insurance coverage for behavioral health treatment and services. 

Under MHPAEA, any insurance plan that covers MH/SUD needs to offer coverage for those services equally to the coverage offered for medical/surgical conditions. This requirement applies to:

  • Copays, coinsurance, and out-of-pocket maximums
  • Limitations on services utilization, such as limits on the number of inpatient days or outpatient visits that are covered
  • The use of care management tools
  • Coverage for out-of-network providers

New Medicaid Parity Rule

For states who want to apply this law to certain Medicaid programs, the Centers for Medicare and Medicaid Services (CMS) released a rule on Mar. 29, 2016 that calls for specific requirements in order to do so. The Medicaid programs that are included in this rule are:

  • Medicaid Managed Care Organizations (MCOs)
  • Children’s Health Insurance Program (CHIP)
  • Medicaid Alternative Benefit Plans (ABPs)

What is required of the included Medicaid Programs Coverage Plans?

The programs involved must share with any enrollee the criteria they use to determine what is considered a “medical necessity” for MH/SUD benefits. Plans must also share the reason for any denial of payment or reimbursement for MH/SUD benefits services. The (MH/SUD) benefit limits need to be comparable to limits on medical/surgical benefits on all fronts, both quantitative limits and not. If the plan includes intermediate and long-term care services, which is up to the state to decide, long-term and intermediate care services are subject to the parity rule.

In order to be compliant with this rule, states have to review both medical/surgical benefits and MH/SUD benefits to ensure parity between the two. All information and documentation regarding this rule must be available on their website. If any changes to the Medicaid programs take place, updates would need to be made accordingly. They also have to include contract provisions in all applicable contracts for Medicaid managed care arrangements that provide services to enrollees.

How will CMS help guide the states in this process?

CMS is currently working with a contractor to develop tools and provide technical assistance to the states in order to:

  • Make sure the states are able to deliver the necessary documentation and information.
  • Ensure that the benefit design and medical management techniques meet the requirements.
  • Provide additional information to states regarding how long-term care services would be classified in the four areas (inpatient, outpatient, pharmacy and emergency).

When are these requirements due?

State plans must comply with the rule within 18 months of the publication date.

What does the rule not do?

This rule only applies to these specified Medicaid programs, not to State Medicaid programs that are only Fee-for-Service.

This rule does not change the Institutes for Mental Disease (IMD) exclusion that prohibits Medicaid payments for services to people ages 21-64 in certain inpatient or residential facilities that provide mostly MH/SUD care. However, the Medicaid Managed Care Rule, which is due to be released soon, may provide further guidance on the IMD exclusion.