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HPC Committees Look at OPP Regulations and Behavioral Health Issues

HPC Committees Look at OPP Regulations and Behavioral Health Issues

July 10, 2015

Earlier this week, two committees of the Health Policy Commission met to:

A presentation combining all the slides from the meeting is posted here.

Proposed Updates to OPP Regulations

The Joint Committee Meeting kicked off by opening the floor to hear public comments on updates to Office of Patient Protection (OPP) regulations on Health Insurance Consumer Protection and Open Enrollment Waivers. 

The consumer protection regulation has been updated to bring the OPP into compliance with amended Massachusetts law. The amended law clarifies that plan members, prospective plan members, and their health care providers may obtain medical necessity criteria, including proprietary criteria, from their health plans. The changes to this regulation will clarify the boundaries of access to proprietary and non-proprietary medical necessity criteria for market participants.

The open enrollment waiver regulation describes the waiver process for consumers who are seeking to buy non-group insurance outside of the open enrollment periods. It has been revised to bring the OPP regulation into compliance with certain eligibility rules that have been changed in the Affordable Care Act and related Massachusetts law.  

Health Care For All and Health Law Advocates weighed in and provided recommendations.

Health Law Advocates staff attorney Laura Goodman proposed that a direct telephone line be established to address the needs of patients seeking medical necessity criteria from insurance companies because currently the staff on call are untrained in collecting or releasing this information in a timely way. In addition, Goodman stated that the regulations could be used as another tool to monitor plan compliance with federal and state mental health parity laws. She suggested that the OPP regulations clarify that when a health plan member, prospective member or provider requests medical necessity criteria or other protocols relevant to a behavioral health service, that individual is entitled, upon request, to a copy of the medical necessity criteria and other protocols that are relevant to comparable medical or surgical services. 

Health Care For All’s Senior Health Policy Manager Suzanne Curry built upon Laura’s testimony to include the recommendation that there should be online components for patients to search for medical necessary criteria through their health plan’s website.  Additionally, HCFA recommends that the deadline for health plans to meet requests for medically necessary criteria be shortened to two business days instead of the current standard of 30 days. Last, HCFA provided supportive comments on the changes made to the insurance open enrollment waiver regulations.

Attorney General’s Report: “Examination of Health Care Cost Trends and Cost Drivers”

Current  approaches separate  “behavioral health ” and  “medical ”  care, resulting in a ripple effect that  impacts the integration of behavioral  health and medical care

Two representatives from the Attorney General’s Office gave a presentation on their most recent AG Cost Trends Report, with its focus on behavioral health. The report’s principal findings were:

  • Current approaches to managing behavioral health benefits and reimbursing providers for behavioral health services pose challenges to effective care coordination.
    • Providers treating behavioral health conditions lack necessary data.
    • Providers and managed behavioral health organizations currently have little to no financial incentive to coordinate care.
    • Complex approaches to managing behavioral health benefits challenge efforts to improve historically low behavioral health reimbursement rates.
  • Behavioral health data lags compared to advances in data for other areas of health expenditures, challenging efforts to improve analysis and promote behavioral health parity. 
    • Lack of comparable and reliable data on behavioral health capacity and utilization constrains effective resource planning.
    • Inconsistent information on prices and payment methodologies constrains our ability to evaluate effective resource planning.
    • Where behavioral health spending is reported, inconsistent definitions and methodologies impede analysis of behavioral health trends.
    • Gaps in behavioral health quality metrics hinder effective quality measurement and analysis.

The report notably points out that Massachusetts commercial and public payers spend an average 2 to 2.5 times as much on patients who have a comorbid chronic medical condition and a behavioral health condition than on patients who have a chronic medical condition alone, and this compounding increase exceeds the simple combination of each conditions independent spending effect.

The report suggests that this may be due to the fact that most health plans in the Commonwealth “carve out” behavioral health benefits from the rest of medical health benefits and subcontract the management and administration of behavioral health benefits to specialized companies called managed behavioral health organizations (“MBHOs”).  MBHOs manage and administer behavioral health benefits for plan members and contract with and pay providers for behavioral health services separately from health plans’ management of medical benefits. Thus, for consumers covered by these plans, separate entities are responsible for managing their behavioral health and medical benefits; including authorizing services and contracting with providers, even though the provider contracts themselves often include behavioral health and medical integration objectives. The report raises the concern that the fragmentation of behavioral health benefit management and reimbursement skews incentives to coordinate care, lacks administrative efficiency, and may negatively impact consumer access to care. 

         -- Michelle Savuto