Federal Mental Health and Addiction Equity Act

1. Definition and Application of Federal Mental Health and Addiction Equity Act Rhonda Robinson Beale,M.D. Health Care Consultant Legna Business Group

2. Health Plans must disclose: • Benefit requirements • Exclusions • Management parameters The Good

3. National Coverage Determination (NCD)states: • whether a particular item or service is covered or excluded. • the population for whom it may be covered. • under what specified situations for payment. National Coverage Determination

4. Under the MHPAEA, the expanded coverage of MH/SUD treatments givesthe opportunity for consumers with chronic condition frombeing pushed into the public sector “safety net” for continuous care and/or paying out-of -pocket for all the care due to maxing out their day and/or visit limits for that coverage year. The Good

5. With the Good comes the Complication • The Federal Mental Health Parity and Addiction Equity Act, (MHPAEA). • The “Good” • creates parity of benefits with medical/surgical coverage, • eliminates previous imposed visit and day limits • The “Complication • must relay more heavily on three processes and sources of evidence: • health technology assessments, • credible practice guidelines and • medical necessity definition.

6. Health Technology Assessment focuses on answering these questions to determine coverage: • What is it? • Is it effective? ( how, when, for who?) • Is special training needed? • Is it comparatively effective and efficient? • Is it safe? Health Technology Assessment

7. Practice guidelines are a set of recommendations on diagnosis, assessment and treatment approaches that have been proven to be effective and/or generally accepted standard of practice as defined by a credible subspecialty organization. • Example: provider recommends swimming with Dolphins as a treatment for depression. • Evidence to support treatment alignment • Use of the scope of acceptable treatment(s) or treatment approaches as outlined in the practice guideline. • Use of the appropriate trained/experienced clinician(s) or milieu to deliver treatments Practice Guidelines

8. The Foundational Components Needed to Execute Medical Necessity How does the Autism field compare to more well established fields?

9. Due to the Kaiser settlement, MCO’s and MBHO’s changed to a standard medical necessity definition as of July 1st 2004. Medical Necessity Transition Timeframe

10. Except where state law or regulation requires a different definition, shall apply the following definition of “Medically Necessary” or comparable term in each agreement with Physicians, Physician Groups, and Physician Organizations: “Medically Necessary” or “Medical Necessity” shall mean health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and (c) not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, the views of Physicians practicing in relevant clinical areas and any other relevant factors. “Medical Necessity “ Redefined

11. “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician/clinician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a)In accordance with generally accepted standards of medical practice(GASMP) and (b)delivered by a clinician who is actively licensed to practice • board eligible or in the case of physician extenders certified • deliver services within the scope of DSM IV and CPT codes covered by insurance • meets the qualifications for credentialing by insurance “Medical Necessity "Definitions- Operationally Defining Key Terms

12. Prudent clinical judgment- is interpreted as the clinical diagnosis and case formulation based on: • the appropriate use of the current DSM or its equivalent in ICD as the classification system for identifying critical clinical factors relevant to the diagnosis and • design treatment interventions that are relevant to the diagnosis, • case formulation and are based on evidencedbased practices guidelines or where absent uses “generally accepted standards of medical practice”. “Medical Necessity "Definitions- Operationally Defining Key Terms

13. Clinically appropriate, defined in terms of type, frequency, extent, site, duration and effectiveness, • • Type –practice guidelines, research models and sources for GASMP, ( expert consensus panels) • • Frequency – based on practice guidelines, successful research models, MBHO and/or national benchmark data • • Extent of treatment– based on generally accepted treatment domains in alignment with LOCG and/or practice guidelines/GASMP • • Site – based on MBHO LOCGs, practice guidelines, specialty society evidence-based recommendations • • Duration – MBHO and/or National benchmarks by like populations • Effective – based on reported response as aligned with expected response according to practice guidelines and/or research modeling or practice based evidence using valid quantitative outcomes tools Key Operational Terms

14. “Generally accepted standards of medical practice” (GASMP)- means standards that are based on credible scientific evidence from: • Published in peer-reviewed medical literature, • Evidenced based consensus panels, • i.e.TexasAlgorithm Group) • Evidenced based specialty society recommendations, • New technological assessments • Credible practice based evidence and not from • Single case studies • Personal opinion "Medical Necessity” Definitions – Operationally Defining Key Terms

15. Medical necessity denials may fit into one of these categories as the bases for the denial. • Inappropriate intensity of services – • too high or too low, • too frequent or not frequent enough • the restrictiveness of the treatment setting is not needed • Treatment not aligned with practice guideline(s) and no justifiable clinical reason for exception. • Delay or inefficient treatment delivery Medical Necessity Denial Categories

16. making medical necessity determinations in individual cases do not always address the particular needs of beneficiaries with chronic conditions.  Chronic care differs from acute care, where the treatment goal is improvement and/or cure, and end of life care, where the treatment goal may be palliation.  The goal for a patient with chronic conditions may be to prevent deterioration and/or to maintain functioning.  A patient with one or more chronic conditions may have a medical need for, and accepted medical and nursing practice may require, observation and assessment, therapeutic care, and care management on an on-going basis. The Next Frontier – Applying Medical Necessity to Chronic Illness

17. Parity sets the expectation of comparable services • Are medical emergency rooms comparable to true psychiatric crisis centers/front room services? The Complication

18. THANK YOU! Rhonda Robinson Beale MDr.robinsonbeale@gmail.com