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Directing Benefits Programs > Behavioral Health Care Benefits > Flashcards

Behavioral Health Care Benefits Flashcards

Module 7

1
Q

What are the most severe mental illnesses

A

Schizophrenia
Bipolar disorder
Major depressive disorder

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2
Q

List the categories into which mental disorder can be loosely categorized

A 
Adjustment disorder
Anxiety disorder
Childhood disorder
Eating disorder
Mood disorder
Cognitive disorder
Personality disorder
Psychotic disorder
Substance-related disorder
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3
Q

Why did insurers start placing limits on mental health care

A

Treatment often continued for indefinite lengths of time and there was too much subjectivity surrounding mental disorders and treatment

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4
Q

What is a behavioral health care carve-out program

A

Program that separates, or carves out, mental health and chemical dependency services from the medical plan and provides through a separate contract known as a Managed Behavioral Health Care Organization (MBHO)

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5
Q

What are the potential savings produced from an MBHO?

A
  1. Usually managed by firms that specialize in behavioral health treatment
  2. Allows large, self-funded employers to offer the same behavioral health benefits across all health plans offered
  3. Allows plan to minimize adverse selection
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6
Q

Drugs that affect psychic function, behavior or experience; they are part of the medical benefit and are generally administered by companies contracting with health plans called pharmacy benefit managers (PGMs).

A

Psychotropic Medications

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7
Q

What challenge do psychotropic medications pose for MBHOs?

A

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

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8
Q

What were the provisions of the Mental Health Parity Act of 1996

A
  1. Prevented group health plans, insurance companies and HMOs from placing lower annual or lifetime dollar limits on mental health benefits than on medical and surgical benefits.
  2. Allowed limits on inpatient days, prescription drugs, outpatient visits and raising deductibles - had the effect of subjecting mental health benefits to dollar limits.
  3. The act only applied to groups that offered mental health benefits and had more than 50 workers.
  4. It did not require plan sponsors to include mental health benefits in their benefit packages.
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9
Q

How does the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) expand on the Mental Health Parity Act of 1996 (MHPA)

A

Continued rules for mental health benefits and amends them to extend to substance use disorder benefits. Further requires that financial requirements and treatment limitations are no more restrictive than those applied to medical/surgical benefits.

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10
Q

What is the first provision of the MHPAEA of 2008?

A
  1. Plans may not impose financial requirements or treatment limitations on MH/SUB benefits that are more restrictive than the “predominant” financial requirements or treatment limits applied to “substantially all” medical and surgical benefits.
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11
Q

What are the six classifications of benefits:

A
  1. Inpatient in-network
  2. Inpatient out-of-network
  3. Outpatient in-network
  4. Outpatient out-of-network
  5. Emergency care
  6. Prescription drugs
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12
Q

Separate cost-sharing requirements for MH/SUD are not allowed even if they are equivalent to those for medical/surgical benefits. FDor example, plans must have a combined __________ that applies to medical/surgical and MH/SUD benefits.

A

Deductible

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13
Q

What are the two new disclosure requirements in MHPAEA of 2008?

A
  1. Plans must make available their criteria for determining medical necessity for MH/SUD treatment
  2. The reason for claim denials for MH/SUD benefits must be made available
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14
Q

Under ACA, mental health and substance use disorder benefits are considered _________ _________.
As such, ______ ______ may not be imposed on these benefits, and ________ ______ are banned under general conditions.

A
  1. Essential benefits
  2. Annual limits
  3. Lifetime limits
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15
Q

Under MHPAEA, if there are an uneven number of tiers, the plan must treat the _____ ___________ financial requirement or _____________ treatment limitation applying to substantially all M/S benefits across all provider tiers in a classification as the ___________ level applied to MH/SUD benefits in the same classification.

A
  1. Least Restrictive
  2. Quantitative
  3. Predominant
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16
Q

Provider placement must be based on reasonable factors, including _____________, quality and ___________ measures (including customer feedback), and relative _____________ rates.

A
  1. Accreditation
  2. Performance
  3. Reimbursement
17
Q

What are the two classifications plans may divide in-network sub-classifications:

A
  1. In-network/preferred

2. In-network/participating

18
Q

If MHPAEA compliance requires changes that increase plan costs by at least 2% in the first year or at least 1% in any subsequent year, the law ________ the plan from MHPAEA for the following plan year.

The exemption lasts for ___ plan year and applies for alternating plan years. The exemption test may be based only on _____ _________ directly attributable to expanding coverage to meet MHPAEA requirements.

A
  1. Exempts
  2. One
  3. Cost Increases
19
Q

Plans covering fewer than ____ current employees, that is, retiree-only plans, are not subject to MHPAEA.

A
  1. Two
20
Q

What is the market composition of behavioral health care benefits?

A

Large groups that buy comprehensive health care and other insurance benefits for their covered members

21
Q

Behavioral benefits are sol through multiple channels including ______ _________ and consulting firms, ______ MBHO sales forces and health carrier sales forces.

A
  1. Large brokerage

2. Large

22
Q

The vast majority of employer-sponsored plans cover ________ and __________ mental health treatment services. They cover __________ mental health treatment services such as residential treatment and partial (or day) hospitalization and cover _________ outpatient services, which can include _________ rehabilitation, case management and wraparound services for children.

A
  1. Inpatient
  2. Outpatient
  3. Intermediate
  4. Intensive
  5. Psychological
23
Q

What are the three basic funding arrangements of an MBHO?

A
  1. Fully insured
  2. Shared risk
  3. Administrative services only (ASO)
24
Q

What is a fully insured arrangement

A

MBHOs assume the financial risk for providing behavioral services paying the claims submitted by providers for behavioral services rendered.

Financial risk falls on the MBHO

Purchasers pay MBHOs a predetermined, fixed premium for assuming financial risk for behavioral treatment costs

25
Q

What is a shared risk

A

Purchasers agree to assume the financial risk for claims payment up to a certain amount. Premiums are based on projected claim costs. If claims exceed a pre-specified amount, the MBHO assumes those claim costs or a 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.

26
Q

What is administrative-services-only (ASO) arrangement

A

MBHO handles medical management, utilization review, benefit and other administrative functions, such as claims payments.

27
Q

What does EAP stand for

A

Employee assistance programs

28
Q

An effective behavioral health program should include an integrated ______/________ dependency benefit that includes inpatient and outpatient services as well as an ___.

A
  1. Health/Chemical

2. EAP

29
Q

Ultimately though, the effectiveness of a behavioral health program depends on what three things;

A
  1. Employee and employer awareness of the program’s services and value
  2. Appropriate use of benefits
  3. How well the behavioral vendor and its network providers prevent and manage costly disorders.
30
Q

List health professional that comprise a typical behavioral health specialty network:

A 
Individual practitioners
Clinical psychologists
Social workers
Master's level therapists
Psychiatric nurses
Psychiatrists
31
Q

Acute inpatient facilities are designed for the most acute treatment needs, meaning individuals who are unable to care for themselves and may be ______ or _________.

A
  1. Suicidal

2. Homicidal

32
Q

Partial hospital programs (day treatment_ offer intensive treatment during the day, but patients return home _________.

A
  1. Overnight
33
Q

Designed for patients who need more intensive treatment than weekly outpatient therapy provides, but they require fewer hours each day than partial or day facilities provide.

A

Intensive Outpatient Programs

34
Q

Describe the following cost containment practices of MBHO’s

A
  1. Care access - MBHO’s require preauthorization to access treatment.
  2. Predictive Modeling and risk assessment - Analyzing claims data and identifying those high risk, potentially high cost members
  3. Performance measurement - data collection

Case management - case managers coordinate the memeber’s care in collaboration with treating providers, facilities and community resources and often work with members and their families to ensure the patients continue to receive the appropriate level of care.

  1. Utilization review and management - Utilization review determines the medical necessity and appropriateness of treatment provided.
  2. Outcomes management - MBHOs have developed tools to assess treatment effectiveness and quantify outcomes
  3. Coordination of care - coordination of medical and behavioral heath care services result in improved treatment outcomes for patients
  4. Depression disease management programs - support the clinician-patient relationship and plan of care and emphasize prevention of disease related exacerbations.
  5. Substance abuse relapse programs - Most MBHOs today offer aftercare programs to their members who relapse
35
Q

What is the highest level of accreditation granted to MBHOs by the National Committee for Quality Assurance

A

Full

36
Q

What are some innovative approaches that might succeed in meeting the critical needs of mental health patients?

A
  1. Proactive disease management programs
  2. Outreach to people who want treatment but do not know how to access it or to find a therapist who is best for them.
  3. Innovative ways of delivering therapy that are most accessible and cost-effective.

Directing Benefits Programs (14 decks)

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