Meeting the Authorization Review Needs for Behavioral Health

Along with the growing incidence of mental health and substance abuse problems in the United States, the Mental Health Parity and Addiction Equity Act and the Affordable Care Act are driving the growing number of behavioral/mental health determinations being dealt with by payers. Learn more about the effect these changing regulations have had and how AllMed’s MedCert can help meet the needs of payers with a first-level pre-authorization solution.

Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 was enacted by Congress to supplement the Mental Health Parity Act of 1996 ensured that large group health plans could not impose annual or lifetime limits on mental health benefits that are less favorable than limits on mental health benefits that are less favorable than limits imposed on medical/surgical benefits. The MHPAEA expanded these parity protections. 

It also added substance use disorder benefits. The MHPAEA also provided that benefits may not be subject to separate cost-sharing requirements or treatment limitations that only apply to mental health/substance use benefits. It further regulated that standards for medical necessity determinations and reasons for any denial of benefits must be disclosed upon request. 

The act also requires insurance plans that cover mental health or substance use disorders to offer coverage for those services that is no more restrictive than coverage for medical/surgical benefits. The requirement applies to co-pays, co-insurance, and out-of-pocket maximums, limitations on services utilization (e.g. limits on number of inpatient days or outpatient visits covered), use of care management tools, and coverage for out-of-network providers, criteria for medical necessity determinations. 

The MHPAEA does not require plans to offer coverage for mental illnesses or substance use disorders in general, or for any specific mental illnesses or substance use disorder or specific treatments/services for mental illnesses or substance use disorders. 

The Affordable Care Act (ACA) further extended the MHPAEA requirements. The final regulations of the MHPAEA only applied to the commercial market but in 2014, the ACA required all small group or individual market plans created after March 23, 2010, to comply with federal parity requirements. 

Qualified Health Plans offered through the Health Insurance Marketplace in every state must include coverage for mental and/or substance use disorders as one of the 10 categories of Essential Health Benefits, and that coverage must comply with the federal parity requirements set forth in the MHPAEA. 

In 2016, the Centers for Medicare & Medicaid Services (CMS) finalized mental health and substance use disorder parity rule for Medicaid and Children’s Health Insurance Program (CHIP). This rule increases access to evidence-based treatment to more than 23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP.

To the meet the growing needs these regulations have driven, AllMed has expanded its MedCert First-Level Pre-Authorization Medical Review Solution to include mental health and addiction. MedCert is designed to provide physician review of suggested denials from utilization review and case management and provides the advantage of freeing up in-house Medical Director (MD) resources. 

MedCert is also a valuable resource to handle changing medical review caseloads and volume fluctuations. With MedCert, expenses associated with medical review activities become variable (based on caseload), instead of fixed. Review of coverage and experimental and investigational procedures and treatments to determine whether clinical criteria have been met is another advantage of MedCert along with quick turnaround times and defensible determinations. 

With the growing number of regulations insuring parity of treatment for mental/behavioral health and medical/surgical claims the number of mental health and substance abuse claims have increased significantly. This has driven the need for a first-level pre-authorization solution to provide high-quality determinations and AllMed’s MedCert Solution is helping payers bridge the gap and improve quality of patient care while controlling overutilization.