Behavioral Health Care Benefits Flashcards
List the categories into which mental disorders can loosely be categorized.
Mental disorders can loosely be categorized into the following categories:
A. Adjustment disorders (e.g., situational stress)
B. Anxiety disorders (e.g., panic disorder)
C. Childhood disorders (e.g., autism)
D. Eating disorders (e.g., anorexia)
E. Mood disorders (e.g., major depressive disorder)
F. Cognitive disorders (e.g., dementia)
G. Personality disorders (e.g., antisocial personality disorder)
H. Psychotic disorders (e.g., schizophrenia)
I. Substance related disorders (e.g., alcohol/drug dependence)
Initially, after World War II, hospitalization for mental illness was covered at the same level of benefits as that of nonpsychiatric benefits. For what reasons, did insurers start to place limits, particularly on outpatient mental health care, soon after that?
It is believed that insurer started to place limits on outpatient mental health care because treatment often continued for indefinite lengths of time and there was much subjectivity surrounding mental disorders and treatment methods.
What were the typical mental health care benefits of health maintenance organizations (HMOs) as they proliferated in the 1980s?
Mental health care coverage under the HMOs was extremely limited and differed significantly from non-mental health care coverage. Hospital coverage was restricted to 30-45 days per mental illness, or 30 or 60 days per year. For medical illnesses, the number of days was usually unlimited.
And for outpatient services, coverage limitations were dramatically lower for mental health treatment then for medical treatment. The most common limitations for mental health outpatient treatment were a maximum dollar limit of $1000 per year and the maximum reimbursement her visit ranging from $25-$40. Call insurance rates also very dramatically between medical and mental coverage.
What is a behavioral health care carveout program and for what reason does it have the potential to produce significant savings?
Viewed by proponents as the solution to the lack of adequate mental health care in most plans, a behavioral health care carveout program is one that separates, or carves out, mental health and chemical dependency services from a medical plan and provides them separately, usually under separate contract and from a separate company known as a managed behavioral healthcare organization (MBHO).
Such a program has the potential to produce significant savings because (1) it is usually managed by firms that specialize in behavioral health treatment; (2) it allows large, self funded employers to offer the same behavioral health benefits across all health plans offered; and (3) it allows a health plan to minimize adverse selection.
What are psychotropic medications and what challenge do they pose for MBHOs?
Psychotropic medications are drugs that affect psychic function, behavior or experience, and they are part of the medical benefit and are generally administered by companies contracting with health plans called pharmacy benefit manager’s (PBM’s). These medications account for a significant part of the overall cost of healthcare because of the chronic nature of many mental illnesses, but a fractionalized system currently exist that prevents optimum management of these medications.
Because MBHOs do not manage the prescription drug benefit but bear the responsibility for managing the behavioral care for their members, they are often unaware if psychotropic medications prescribed to their members are of the appropriate types and dosages, or if there are appropriate interventions during treatment to ensure their members are medication compliant.
What are the provisions of the mental health parity act of 1996 (MHPA) and the reasons it largely failed to accomplish its objective?
The act was passed to establish parity between mental health benefits and other health insurance. The act prevents group health plans (it does not apply to the individual insurance market), insurance companies and HMOs from placing lower annual or lifetime dollar limits on mental health benefits then for medical and surgical benefits offered under the plan. The law, however, does allow for limits on inpatient stays, prescription drugs, outpatient visits and raising deductibles which, in fact, has the effect of subjecting mental health benefits to dollar limits. The act applies only to groups that offer mental health benefits and have more than 50 workers. It does not require plan sponsors to include mental health benefits in their benefit packages. The law also does not apply to substance-abuse and chemical dependency treatment.
How does the mental health parity and addiction equity act of 2008 (MHPAEA) expand on the mental health parity act of 1996 (MHPA)?
MHPA required parity only in annual or lifetime dollar limits and did not extend to substance use disorder benefits. MHPAEA continues the MHPA rules as to limits for mental health benefits and amends them to extend to substance use disorder benefits as well.
MHPAEA further requires that financial requirements and treatment limitations applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than those applied to medical/surgical benefits.
MHPAEA retains the small employer exemption contained in MHPA; and, like MHPA, does not require group plans to include MH/SUD benefits in their plans. Rather, a plan which offers both medical/surgical and MH/SUD benefits must comply with the parity provisions. (MHPAEA modified the increased cost exception contained in MHPA. Under MHPAEA, a plan is exempt from the parity rules if they increase the plan’s premium cost by more than 2% in the first year in which the act applies and more than 1% in subsequent years.
What are the provisions of the mental health parity and addiction equity act of 2008 (MHPAEA)?
The provisions of MHPAEA are:
A). Plans may not impose financial requirements (such as deductibles and coinsurance) or treatment limitations on MH/SUD benefits that are more restrictive than the “predominant” financial requirements or treatment limits apply to “substantially all” medical/surgical benefits. The law requires parity for both quantitative and nonquantitive treatment limitations. Quantitive treatment limitations include frequency of treatment, number of visits, days of coverage and other similar limits. Examples of nonquantitative treatment and limitations include medical management standards and formulary design.
B). The parity requirements apply separately to each of the six classifications of benefits:
1) inpatient in network 2) inpatient out of network 3) . Outpatient in network 4) outpatient out of network 5) emergency care 6) prescription drugs
C). Separate cost sharing requirements for MH/SUD benefits are not allowed even if they are equivalent to those for medical/surgical benefits. For example, plans must have a combined deductible that applies to medical/surgical and MH/SUD benefits.
D). The law includes two new disclosure requirements. First, plans must make available their criteria for determining medical necessity for MH/SUD treatment. Second, the reason for claim denials for MH/SUD benefits must be made available. A plan subject to ERISA can satisfy this requirement by following ERISA claim denial procedures for group health plans.
NOTE: under the patient protection and affordable care act of 2010 (PPACA),mental health and substance use disorder benefits are considered essential benefits. As such, annual limits may not be imposed on these benefits after plan years beginning 2014 and lifetime limits are banned under general conditions.
Describe the nature of most severe mental illnesses.
The most severe mental illnesses such as schizophrenia, bipolar disorder and major depressive disorder are generally considered biologically-based disorders that affect the brain, profoundly disrupting a person’s thinking, feeling, mood, ability to relate to others and capacity for coping with the demands of life. Non-biologically based mental disorders can also severely impact on individuals functioning.
What is the market composition of behavioral health care benefits?
The majority of behavioral health care benefits sold in the United States today are purchased by large groups that by comprehensive healthcare and other insurance benefits for their covered members. The smaller the group, the more likely it is that behavioral benefits are sold as an integrated part of the general health plan, which may or may not have a specialty MBHO provide the behavioral benefit. Behavioral benefits are sold through multiple channels including large brokerage and consulting firms, large MBHO sales forces and health carrier sales forces.
Describe the typical plan features of behavioral health care benefit plans.
The vast majority of employer-sponsored plans cover inpatient and outpatient mental health treatment services. They cover intermediate mental health treatment services such as residential treatment and partial (or day) hospitalization and cover intensive outpatient services, which can include psychological rehabilitation, case management and wraparound services for children. Many plans also include a parity benefit - often called “a severe mental illness” benefit that specifies which disorders are covered under their state parity law.
Need to know-review answer.
The health insurance portability and accountability act plays a particularly important part in protecting sensitive patient information gathered during behavioral treatment.
What are the basic types of funding arrangements oven MBHO?
1) . In fully insured arrangements, MBHOs assume the financial risk for providing behavioral services paying the claim submitted by providers for behavioral services rendered. Financial risk falls on the MBHO. When overall plan costs exceed expected levels, the MBHO absorbs those increased costs. Purchasers pay MBHO’s a predetermined, fixed premium for assuming financial risk for behavioral treatment costs. On average, a monthly premium for a fully insured, full risk behavioral plan, excluding EAP fees, ranges between 3% and 6% of a medical plans premium.
2) . A variation on a fully insured funding arrangement is a shared risk one, in which purchasers agree to assume the financial risk for claims payment up to a certain amount. Premiums are based on projected claims cost. If claims exceed a pre-specified amount, the MBHO assumes those claim costs or percentage of those costs. If the claims come in below a pre-specified amount, the balance can be shared by the MBHO and client or refunded to the client.
3) . Under an administrative services only (ASO) arrangement, and MBHO, for a fee, will handle medical management, utilization review, benefit and other administrative functions, such as claims payments. Often called a self-funded or self-insured arrangement, the purchaser assumes the financial risk of the healthcare costs for its members. The larger the group, the more likely it is to self-fund because the financial risk is spread across a greater number of employees and its budget is large enough to absorb the risk. A key advantage of an ASO is that employers can offer the same benefit to employees working in different states because ERISA exempts self-funded health plans from compliance with state laws and regulations.
How have employee assistance programs (EAPs) evolved?
EAP’s originally focused on substance abuse problems, but today take a comprehensive approach to support members with a range of employee and family issues. Some include proactive prevention and health and wellness programs. Some EAPs also provide human resource support through management consultation, on-site employee and employer seminars, and critical stress management after catastrophic workplace events.
What is involved in providing an effective behavioral health program?
An effective behavioral health program should include an integrated health/chemical dependency benefit that includes inpatient and outpatient services as well as an EAP. Ultimately though, the effectiveness of a behavioral health program depends on (1) employee and employer awareness of the program services and value; (2) appropriate use of the benefits; and (3) how well the behavioral vendor and it’s network providers prevent and manage costly disorders.
