Behavioral Health

HIPAA

Priority Health has always been committed to protecting the confidentiality of our members’ personal and medical information in all settings. We have a special committee dedicated to monitoring all of our processes and procedures to protect this important information. Our Notice of Privacy Practices online, or is available upon request.

The Department of Health and Human Services (HHS) issued the Standards for Privacy Individually Identifiable for Health Information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to provide the first comprehensive federal protection for the privacy of personal health care information.

HIPAA privacy regulations went into effect on April 14, 2003. Health plans and health care providers are all affected by the regulations. This means we must all evaluate how we obtain, store, retrieve and communicate personal health information about members and patients.

While the privacy regulations are more complex than can be addressed in one article, here are some helpful hints for using passwords to protect the security, privacy and integrity of patient records kept in computer systems. Passwords are not specifically required under HIPAA, but are commonly recommended by HIPAA experts. When setting a password, keep the following tips in mind:

• Avoid using names that are easily associated with an individual.
• Avoid using AIP codes or telephone numbers.
• Use alpha-numeric passwords that include special characters.
• For purposes of accountability, do not share passwords.
• Do not post a password near the computer terminal.
• Change passwords periodically.

For additional information, visit these Department of Health and Human Services websites: aspe.hhs.gov/datacncl/adminsim.shtml and hhs.gov/ocr/hipaa.

Clinical practice guidelines

Clinical practice guidelines are developed in collaboration with area physicians based on standards established by national organizations. Each guideline addresses a specific condition, diagnosis, therapeutic intervention, patient education/follow-up, continuity and coordination of care. Guidelines are available for ADHD, alcohol/substance use, depression, pain management and many other topics. Review the clinical practice guidelines.

Mental health parity

Integrating medical and behavioral health care is a primary objective at Priority Health. The Mental Health Parity and Addiction Equity Act of 2008, which was passed last fall, supports this goal. We’re well positioned to comply with this federal law.

What is mental health parity?
The Mental Health Parity and Addiction Equity Act of 2008 ensures that Americans have access to non-discriminatory mental health and substance abuse coverage through their health insurance plans. This act significantly expands the Mental Health Parity Act of 1996. Detailed implementation regulations will be issued by the Department of Labor, Health and Human Services and the Internal Revenue Service by October 3, 2009. However, health plans must comply with the act by that same date (whether or not the regulations have been issued).

What the act requires
The law requires parity (equal treatment) between behavioral health benefits (mental health/ substance use disorders) and medical/surgical benefits.

• Financial – equity in deductibles, copayments, coinsurance, out-of-pocket limits, lifetime limits, and annual limits
• Treatment Limitations – equity in limits on the frequency of treatment, number of visits, out-of-network provider access, days of coverage or other similar limits on the scope or duration of treatment

A group health plan can still manage the benefits under the terms and conditions of the plan, including medical necessity criteria. The law also doesn’t mandate that all behavioral health conditions are covered. Instead, it only requires coverage of conditions as defined under the terms of each plan.

Who it impacts
This law applies to both fully funded and self-funded group health plans with more than 50 employees. Group size is determined using Internal Revenue Code “controlled group” rules.

When it goes into effect
The requirements apply to new contracts and renewals on or after October 3, 2009. The effective date for groups with union contracts could be delayed until the contract is terminated.

Frequently asked questions
Is compliance with mental health parity required for all groups and members?
No. This law applies to groups with more than 50 employees (including Priority Health Medicare offered as a group plan). Priority Health will assume that all groups with 51 or more employees (all employees, not just eligible employees) are required to comply unless a group tells us otherwise.

Small groups (50 employees or less) and individual plans are exempt from these requirements. Group size is determined using Internal Revenue Code "controlled group" rules.

Will mental health and substance abuse benefits change?
Yes, but only for groups affected by this law.

• Affected groups will have "parity benefits." We’ll implement a new compliant benefit design for mental health and substance abuse services.
• Groups of 50 or fewer employees will have "non-parity benefits." We’ll maintain our current mental health and substance abuse benefit design(s).

What is the mental health parity benefit design?
Here are the basics of the mental health parity benefit design for groups of 51 or more employees:

• "Mental health parity" benefits refers to both mental health and substance abuse services.
• Day and visit limits are removed. (No more 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 specialist level for services provided by psychiatrists (including medication management).
• Coinsurance (for inpatient services) is equal to medical services coinsurance level.
• Deductibles and out-of-pocket maximums will be applied in the same manner as other medical services.
• Out-of-network deductibles and coinsurance will be applied in the same manner as other medical services.
• Prior authorization requirements for behavioral health services remain in place.

Small groups (50 or less employees) or individual plans (SMIC, conversion, etc.) will not change at this time.

Does this law take benefits away from members?
No. It does require some changes in the way financial limits and treatment limits are applied.

Does mental health parity mean that members will have unlimited mental health and substance abuse benefits?
No. Although day and visit limits are removed, the health plan can still manage these benefits under its medical criteria policies. Coverage limitations and/or non-covered services will be outlined in the Certificate of Coverage or Insurance Policy for fully funded members and the SPD for self-funded members.