Thursday, November 28, 2013

5 Reasons the EDC is Thankful this Year

The EDC has so many reasons to be thankful. We’ve achieved so many wonderful things this year. We hope you spend today celebrating your thankfulness for the good things in your life. We’ve decided to share our top five reasons we’re thankful this Thanksgiving, and we hope they’ll encourage you as well.  

1. We held our most widely attended lobby day in April, and another incredibly successful lobby day in September. (click to read more)

2. The FREED Act was introduced in May. (click to read more)

3. Favorable Parity Regulations issued in November. (click here to read more)

4. Our Members! The EDC Coalition Members are the most committed, supportive leaders in the eating disorders community.

5. You!  Thank you for supporting our legislative strategy, joining us on lobby day, sharing your stories and contacting your members of Congress.

Wednesday, November 20, 2013

More on Parity

One of our board members, Katherine Swain McClayton, Manager of Aftercare Planning at the Oliver-Pyatt Centers  has written an excellent blog on the Parity Rules.

Check out her blog here:

Tuesday, November 12, 2013

Parity Final Rule and Eating Disorders

If you’ve read our previous blog, you know that the final rule for MHPAEA came out on Friday. EDC has taken a look at the regulation to determine how we anticipate it will affect eating disorders policy, and what we anticipate the implications to be.

As a reminder, MHPAEA applies only to health plans provided by employers with 50 workers or more, and individual plans purchased through the Exchange. These rules do not apply to people in government health insurance programs such as Medicaid or Medicare.

Overall, the EDC, like many mental health advocacy organizations, is very pleased with this final rule. This is a historic first step in ensuring that people with eating disorders are able to receive the treatment that they need to recover. The final rule does clarify that insurers must cover mental health disorders at parity with medical disorders. There are three primary issues in the regulation we want to highlight: residential treatment, plan standards and disclosure requirements. All three of these areas contain substantial victories for people trying to get coverage for eating disorders.

1. Residential Treatment

While the rule doesn't require that residential services be covered, it does say that if insurers offer "post-acute care services," then they must cover residential treatment and other intermediate services for mental health.

For example, if a plan classifies care in skilled nursing facilities or rehabilitation hospitals as inpatient benefits, then the plan must also treat any covered care in residential treatment facilities for mental health as an inpatient benefit.  This means that if your insurance plan covers, for example, residential rehabilitation after an accident, it must also cover comparable residential or inpatient treatment for eating disorders.

People with eating disorders have been consistently denied inpatient and residential care, while their insurance plans cover comparable medical services. The EDC has long argued this is in violation with MHPAEA, the regulations explicitly clarify this.

2. Medical Necessity Disclosure Requirements

The rule clarifies that people are entitled to information about the standards used by health plans to determine what kind of treatment they cover.
That is, the final regulations require plan administrators to make the plan’s medical necessity determination criteria available upon request to potential participants, beneficiaries, or contracting providers. This information is particularly valuable if people wish to file a complaint alleging that their eating disorder was not treated comparably to a medical one.

People receiving treatment for eating disorders have, unfortunately, experienced coverage denials (typically, inpatient or residential) because of medical necessity. For many consumers it has been nearly impossible to understand how the insurance company made their determination.  Insurers have refused to disclose how the determination of ‘medical necessity ’was made. In a tremendous victory, these regulations clarify that the rationale behind these decisions must be disclosed.

3. Plan Standards

Another regulation in the final rules we want to highlight is plan standards.  In setting up their provider network, if an insurer does not require a patient to go out of state to access post-acute care medical services, then it can not force patients with mental illnesses out of state to access behavioral health residential treatment services.

Additionally, an insurer may no longer exclude coverage for inpatient or residential, out-of-network treatment of mental health disorders when obtained outside of the state where the policy is written, when no similar exclusion  exists for medical benefits exists.

In fact, the final rule added two additional examples of non-quantitative treatment limits (NQTL) to the illustrative list: network tier design and restrictions based on geographic location, facility type, provider specialty and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage. The new
examples clarify that plan or coverage restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services must comply with the NQTL parity standard.

Friday, November 8, 2013

EDC Succeeds in Parity Push!

The EDC has worked tirelessly, in the past two years to put pressure on the Administration to release the regulations for the Mental Health Parity Addiction Equity Act of 2008 and to clarify that eating disorders must be covered at parity (click here for more).

This morning the Department of Health and Human Services released their final regulations on the Mental Health Parity and Addiction Equity Act of 2008.  The EDC was part of a conversation this morning with HHS and the Substance Abuse Mental Health Services Administration where they outlined the final regulations. The EDC is excited about a number of the provisions.

While the final rule doesn’t require that residential services be covered, it does require that if a managed care organization (MCO) or health insurers offers “post-acute care services,” then they also must cover residential treatment and other intermediate services on the behavioral health side. Simply put, it means that if a health insurance plan covers chemotherapy [a post-acute oncology intervention after hospitalization], then it must cover residential treatment of substance use disorders or eating disorders. The rule ensures that parity applies to intermediate levels of care received in residential treatment or intensive outpatient settings.

Another, tremendous win for us, is that the final rule clarifies that parity applies to all plan standards, including geographic limits, family type limits, network adequacy.  As many of you have encountered, you’ve needed to travel out of state to treatment centers so this is tremendous.

The EDC is particularly encouraged by the network disclosure requirements, the final rule will require that MCO’s/Insurers disclose medical necessity definitions and the process used to construct NQTL.  This has long been a difficulty faced by people denied coverage for their eating disorders.

This is a tremendous victory for all of those who have struggled through getting insurance coverage at parity. Thank you to those who shared your stories with us, called your Members to advocate for parity, and of course, attended our lobby days. This is our victory together!

We are continuing to comb through the regulations, and will soon let you know what this all means for you. Stay tuned to our blog, or follow us on twitter, or like us on Facebook to get immediate updates.  

Tuesday, November 5, 2013

Help Support the EDC

One of our junior board members is supporting the EDC. Please consider supporting her, and supporting the EDC!

You can access her brochure here: