Flashcards in Behavioral Health Care Benefits Deck (36)
What are the most severe mental illnesses
Major depressive disorder
List the categories into which mental disorder can be loosely categorized
Why did insurers start placing limits on mental health care
Treatment often continued for indefinite lengths of time and there was too much subjectivity surrounding mental disorders and treatment
What is a behavioral health care carve-out program
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)
What are the potential savings produced from an MBHO?
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
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).
What challenge do psychotropic medications pose for MBHOs?
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
What were the provisions of the Mental Health Parity Act of 1996
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.
How does the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) expand on the Mental Health Parity Act of 1996 (MHPA)
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.
What is the first provision of the MHPAEA of 2008?
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.
What are 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
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.
What are the two new disclosure requirements in MHPAEA of 2008?
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
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.
1. Essential benefits
2. Annual limits
3. Lifetime limits
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.
1. Least Restrictive
Provider placement must be based on reasonable factors, including _____________, quality and ___________ measures (including customer feedback), and relative _____________ rates.
What are the two classifications plans may divide in-network sub-classifications:
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.
3. Cost Increases
Plans covering fewer than ____ current employees, that is, retiree-only plans, are not subject to MHPAEA.
What is the market composition of behavioral health care benefits?
Large groups that buy comprehensive health care and other insurance benefits for their covered members
Behavioral benefits are sol through multiple channels including ______ _________ and consulting firms, ______ MBHO sales forces and health carrier sales forces.
1. Large brokerage
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.
What are the three basic funding arrangements of an MBHO?
1. Fully insured
2. Shared risk
3. Administrative services only (ASO)
What is a fully insured arrangement
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
What is a shared risk
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.
What is administrative-services-only (ASO) arrangement
MBHO handles medical management, utilization review, benefit and other administrative functions, such as claims payments.
What does EAP stand for
Employee assistance programs
An effective behavioral health program should include an integrated ______/________ dependency benefit that includes inpatient and outpatient services as well as an ___.
Ultimately though, the effectiveness of a behavioral health program depends on what three things;
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.