The Centers for Medicare and Medicaid Services (CMS) recently published a final rule that seeks to strengthen access to mental health and substance abuse benefits for Medicaid and CHIP beneficiaries. The rule provides states with detailed guidance on how the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) should be applied to Medicaid and CHIP programs. The MHPAEA makes it easier for patients to get the care they need by requiring coverage of behavioral health treatment and services that is no more restrictive than the coverage for medical/surgical conditions.

The rule seeks to prevent inequity in access to services between Medicaid and commercial markets by aligning Medicaid managed care plans (MCOS), Medicaid alternative benefit plans (ABPs) and CHIP programs with protections that are already required of many private health plans through the MHPAEA.

The final rule addresses the parity standards in terms of care provided through Managed Care Organizations, ABPs and CHIP plans by:

• Requiring Medicaid MCOs (or State) to disclose information on mental health and substance use disorder benefits as well as criteria for medical necessity determinations upon request.
• Requiring Medicaid MCOs (or State) to disclose the reason for any denial or reimbursement or payment for service with respect to mental health and substance use disorder benefits
• Requiring states to include contract provisions requiring compliance with parity standards (mental health as well as long term care services for mental health and substance abuse) in all Medicaid MCO arrangements.

(States, like WI, who do not have a separate CHIP program and provide full coverage of EPSDT services (HealthCheck) will be deemed in compliance with the parity requirements. However, all the parity standards that apply to private plans will apply to CHIP plans that don’t provide the full EPSDT coverage.)

These new rules move us in the right direction. However, as a blog post from the Center on Budget and Policy Priorities (CBPP) rightly points out, they need to be coupled with strong enforcement by both the state and federal government. The CBPP blog points out that there has been difficulty in the enforcement of the MPHAEA parity requirements for the private market that went into effect in 2013, and claims for mental health care get denied at a greater proportion than for medical care.

In this past session, the Wisconsin Assembly passed a number of bills to help improve access to mental health and substance use services, but some did not make it through the Senate (see our legislative summary on health bills). Hopefully, the current scrutiny around the lack of access to mental health and substance use services (especially in light of the opiate epidemic that has hit many WI communities), as well as these new rules clarifying how the 2008 mental health and substance abuse parity law should be applied to Medicaid, will move the state closer in the effort to offer greater access to mental health and substance abuse services.

Sashi Gregory