Mental health parity changes 10/3/2009

The Mental Health Parity and Addiction Equity Act of 2008 ensures access to non-discriminatory mental health and substance abuse coverage. The law requires parity (equal treatment) between mental health benefits and medical/surgical benefits. "Mental health" refers to both mental health and substance abuse services.

Plans/patients impacted by this law

• Mental health parity applies to plans with more than 50 employees, whether they are fully funded, self-funded, or employer-sponsored Medicare groups.
• Small groups of 50 employees or less are exempt.
• Individual plans are exempt.

Changes apply to new contracts and to contract renewals on or after Oct. 3, 2009.

• Affects only members of group plans of 51 or more (small employer groups are not impacted)
• Day and visit limits are removed.  This eliminates the need for 2 for 1 partial inpatient days and 2 for 1 group therapy benefits.
• Copays for outpatient services will be at the PCP office visit level for services provided by MSWs and psychologists and at the Specialist level for services provided by psychiatrists.
• Medication management (procedure code 90862) copays will be handled as follows:
  
  • PCP copay will now apply to medication management services handled in a PCP office.
  • PCP office visit copay applies to services provided by MSWs and psychologists.
  • Specialist office visit copay applies for services provided by psychiatrists.
• Coinsurance for inpatient services is equal to medical services coinsurance level.
• All deductibles and out-of-pocket maximums will be applied in the same manner as other medical services.
• Prior authorization policies have not changed. Go to details on requesting behavioral health authorizations.
  

For more information, view the Mental Health Parity overview chart (101KB PDF)

Use the Member Inquiry tool to see a patient's specific coverage details.

You must be logged in as a provider to use the Member Inquiry tool. Behavioral Health coverage information is scheduled to be added on November 1, 2009.

Case reviews & utilization

• Services must be medically necessary, be covered under our medical policies, follow established standards of care and result in measurable symptom improvement.
  Go to medical necessity criteria.
  Go to medical policies.
  
• Outpatient case reviews are not required.
• Priority Health will run monthly utilization reports. If the reports indicate a member's care needs review, a Priority Health case manager will contact you.