42 CFR § 417.460 - Disenrollment of beneficiaries by an HMO or CMP.

§ 417.460 Disenrollment of beneficiaries by an HMO or CMP.(a)General rule. Except as provided in paragraphs (b) through (i) of this section, an HMO or CMP may not -

(1) Disenroll a Medicarebeneficiary; or

(2) Orally or in writing, or by any action or inaction, request or encourage a Medicareenrollee to disenroll.

(b)Bases for disenrollment: Overview -

(1)Optional disenrollment. Generally, an HMO or CMP may disenroll a Medicareenrollee if he or she -

(i) Fails to pay the required premiums or other charges;

(ii) Commits fraud or permits abuse of his or her enrollment card; or

(iii) Behaves in a manner that seriously impairs the HMO's or CMP's ability to furnish health care services to the particular enrollee or to other enrollees.

(2)Required disenrollment. Generally, an HMO or CMP must disenroll a Medicareenrollee if he or she -

(i) Moves out of the HMO's or CMP's geographic service area or is incarcerated;

(ii) Fails to convert to the risk provisions of the HMO's or CMP's Medicare contract;

(iii) Loses entitlement to Medicare Part B benefits;

(iv) Is not lawfully present in the United States; or

(v) Dies.

(3)Related provisions. Specific requirements, limitations, and exceptions are set forth in paragraphs (c) through (j) of this section.

(c)Failure to pay premiums or other charges
to professional competence or§ 460.166
(5) The PACE program agreement
with  CMS  and  the  State  administering  

agency is not renewed or is terminated.
(6)  The  PACE  organization  is  unable  
to offer health care services due to the

loss of State licenses or contracts with

outside providers.
(b)  Disruptive  or  threatening  behavior.  
For  purposes  of  this  section,  a  partici-

pant who engages in disruptive or

threatening behavior refers to a partic-

ipant  who  exhibits  either  of  the  fol-

lowing:
(1) A participant whose behavior
jeopardizes  his  or  her  health  or  safety,  

or the safety of others; or
(2)  A  participant  with  decision-mak-
ing  capacity  who  consistently  refuses  

to  comply  with  his  or  her  individual  

plan  of  care  or  the  terms  of  the  PACE  

enrollment agreement.
(c) Documentation of disruptive or
threatening  behavior.  If  a  PACE  organi-
zation  proposes  to  disenroll  a  partici-

pant  who  is  disruptive  or  threatening,  

the  organization  must  document  the  

following  information  in  the  partici-

pant’s medical record:
(1) The reasons for proposing to
disenroll the participant.
(2)  All  efforts  to  remedy  the  situa-
tion.
(d) Noncompliant behavior. (1) A PACE
organization may not disenroll a PACE

participant  on  the  grounds  that  the  

participant  has  engaged  in  noncompli-

ant  behavior  if  the  behavior  is  related  

to  a  mental  or  physical  condition  of  

the participant, unless the partici-

pant’s  behavior  jeopardizes  his  or  her  

health  or  safety,  or  the  safety  of  oth-

ers.
(2)  For  purposes  of  this  section,  non-
compliant  behavior  includes  repeated  

noncompliance with medical advice

and  repeated  failure  to  keep  appoint-

ments.
(e)  State  administering  agency  review  
and final determination. Before an invol-
untary  disenrollment  is  effective,  the  

State  administering  agency  must  re-

view it and determine in a timely man-

ner  that  the  PACE  organization  has  

adequately documented acceptable

grounds for disenrollment.
§ 460.166 Effective date of disenrollment.
(a)  In  disenrolling  a  participant,  the  
PACE  organization  must  take  the  fol-

lowing actions:
(1) Use the most expedient process al-
lowed under Medicare and Medicaid

procedures,  as  set  forth  in  the  PACE  

program agreement.
(2) Coordinate the disenrollment date
between  Medicare  and  Medicaid  (for  a  

participant who is eligible for both

Medicare and Medicaid).
(3) Give reasonable advance notice to
the participant.
(b)  Until  the  date  enrollment  is  ter-
minated, the following requirements

must be met:
(1)  PACE  participants  must  continue  
to  use  PACE  organization  services  and  

remain liable for any premiums.
(2) The PACE organization must con-
tinue to furnish all needed services.
§ 460.168 Reinstatement  in  other  Medi-care and Medicaid programs.
To facilitate a participant’s rein-
statement  in  other  Medicare  and  Med-

icaid programs after disenrollment, the

PACE  organization  must  do  the  fol-

lowing:
(a) Make appropriate referrals and
ensure medical records are made avail-

able to new providers in a timely man-

ner.
(b) Work with CMS and the State ad-
ministering agency to reinstate the

participant in other Medicare and Med-

icaid  programs  for  which  the  partici-

pant is eligible.
§ 460.170 Reinstatement in PACE.
(a)  A  previously  disenrolled  partici-
pant may be reinstated in a PACE pro-

gram.
(b)  If  the  reason  for  disenrollment  is  
failure  to  pay  the  premium  and  the  

participant  pays  the  premium  before  

the effective date of disenrollment, the

participant  is  reinstated  in  the  PACE  

program with no break in coverage.
§ 460.172 Documentation of disenrollment.
A  PACE  organization  must  meet  the  
following requirements:
(a) Have a procedure in place to docu-
ment the reasons for all voluntary and

involuntary disenrollments.

(1)Basic rule. Except as specified in paragraph (c)(2) of this section, an HMO or CMP may disenroll a Medicareenrollee who fails to pay premiums or other charges imposed by the HMO or CMP for deductible and coinsurance amounts for which the enrollee is liable, if the HMO or CMP -

(i) Can demonstrate to CMS that it made reasonable efforts to collect the unpaid amount;

(ii) Gives the enrollee written notice of disenrollment, including an explanation of the enrollee's right to a hearing under the HMO's or CMP's grievance procedures; and

(iii) Sends the notice of disenrollment to the enrollee before it notifies CMS.

(2)Exception. If the enrollee fails to pay the premium for optional supplemental benefits (that is, a package of benefits that an enrollee is not required to accept), but pays the basic premium and other charges, the HMO or CMP may discontinue the optional benefits but may not disenroll the beneficiary.

(3)Good cause and reinstatement. When an individual is disenrolled for failure to pay premiums or other charges imposed by the HMO or CMP for deductible and coinsurance amounts for which the enrollee is liable, CMS (or a third party to which CMS has assigned this responsibility, such as an HMO or CMP) may reinstate enrollment in the plan, without interruption of coverage, if the individual shows good cause for failure to pay and pays all overdue premiums or other charges within 3 calendar months after the disenrollment date. The individual must establish by a credible statement that failure to pay premiums or other charges was due to circumstances for which the individual had no control, or which the individual could not reasonably have been expected to foresee.

(4)Exception for reinstatement. A beneficiary's enrollment in the plan will not be reinstated if the only basis for such reinstatement is a change in the individual's circumstances subsequent to the involuntary disenrollment for non-payment of premiums or other charges.

(d)Enrollee commits fraud or permits abuse of the enrollment card -

(1)Basis for disenrollment. An HMO or CMP may disenroll a Medicarebeneficiary if the beneficiary -

(i) Knowingly provides, on the application form, fraudulent information that materially affects the beneficiary's eligibility to enroll in the HMO or CMP; or

(ii) Intentionally permits others to use his or her enrollment card to obtain services from the HMO or CMP.

(2)Notice requirement. If disenrollment is for either of the reasons specified in paragraph (d)(1) of this section, the HMO or CMP must give the beneficiary a written notice of termination of enrollment.

(i) The notice must be mailed to the enrollee before submission of the disenrollment notice to CMS.

(ii) The notice must include an explanation of the enrollee's right to have the disenrollment heard under the grievance procedures established in accordance with § 417.436.

(3)Report to the Inspector General. The HMO or CMP must report to the Office of the Inspector General of the Department any disenrollment based on fraud or abuse by the enrollee.

(e)Disenrollment for cause -

(1)Basis for disenrollment. An HMO or CMP may disenroll a Medicareenrollee for cause if the enrollee's behavior is disruptive, unruly, abusive, or uncooperative to the extent that his or her continuing enrollment in the HMO or CMP seriously impairs the HMO's or CMP's ability to furnish services to either the particular enrollee or other enrollees.

(2)Effort to resolve the problem. The HMO or CMP must make a serious effort to resolve the problem presented by the enrollee, including the use (or attempted use) of internal grievance procedures.

(3)Consideration of extenuating circumstances. The HMO or CMP must ascertain that the enrollee's behavior is not related to the use of medical services or to mental illness.

(4)Documentation. The HMO or CMP must document the problems, efforts, and medical conditions as described in paragraphs (e)(1) through (e)(3) of this section.

(5)CMS review of an HMO's or CMP's proposed disenrollment for cause.

(i)CMS decides on the basis of review of the documentation submitted by the HMO or CMP, whether disenrollment requirements have been met.

(ii)CMS makes this decision within 20 working days after receipt of the documentation material, and notifies the HMO or CMP within 5 working days after making its decision.

(6)Effective date of disenrollment. If CMS permits an HMO or CMP to disenroll an enrollee for cause, the disenrollment takes effect on the first day of the calendar month after the month in which the HMO or CMP gives the enrollee a written notice of disenrollment that meets the requirements set forth in paragraphs (d)(2)(i) and (d)(2)(ii) of this section.

(f)Enrollee moves out of the HMO's or CMP's geographic area -

(1)Basic rules -

(i)Disenrollment. Except as provided in paragraph (f)(2) of this section, an HMO or CMP must disenroll a Medicareenrollee who moves out of its geographic area if the HMO or CMP establishes, on the basis of a written statement from the enrollee, or other evidence acceptable to CMS, that the enrollee has permanently moved out of its geographic area.

(A)Incarceration. The HMO or CMP must disenroll an individual if the HMO or CMP establishes, on the basis of evidence acceptable to CMS, that the individual is incarcerated and does not reside in the geographic service area of the HMO or CMP per § 417.1.

(B)Notification by CMS of incarceration. When CMS notifies an HMO or CMP of disenrollment due to the individual being incarcerated and not residing in the geographic service area of the HMO or CMP, as per § 417.1, the disenrollment is effective the first of the month following the start of incarceration, unless otherwise specified by CMS.

(C)Exception. The exception in paragraph (f)(2) of this section does not apply to individuals who are incarcerated.

(ii)Notice requirement. The HMO or CMP must comply with the notice requirements set forth in paragraph (d)(2) of this section.

(iii)Effect on geographic area. Failure to disenroll an enrollee who has moved out of the HMO's or CMP's geographic area does not expand that area to encompass the location of the enrollee's new residence.

(2)Exception. An HMO or CMP may retain a Medicareenrollee who is absent from its geographic area for an extended period, but who remains within the United States as defined in § 400.200 of this chapter if the enrollee agrees. For purposes of this exception, the following provisions apply:

(i) An absence for an extended period means an uninterrupted absence from the HMO's or CMP's geographic area for more than 90 days but less than 1 year.

(ii) The HMO or CMP and the enrollee may mutually agree upon restrictions for obtaining services while the enrollee is absent for an extended period from the HMO's or CMP's geographic area. However, restrictions may not be imposed on the scope of services described in § 417.440.

(iii)HMOs and CMPs that choose to exercise this exception must make the option available to all Medicareenrollees who are absent for an extended period from their geographic areas. However, HMOs and CMPs may limit this option to enrollees who go to a geographic area served by an affiliated HMO or CMP.

(iv) As used in this paragraph, “affiliated HMO or CMP” means an HMO or CMP that -

(A) Is under common ownership or control of the HMO or CMP that seeks to retain the absent enrollees; or

(B) Has in effect an agreement to furnish services to enrollees who are on an extended absence from the geographic area of the HMO or CMP that seeks to retain them.

(v) When the enrollee returns to the HMO's or CMP's geographic area (even temporarily), the restrictions of § 417.448(a) (which limit payment for services not provided or arranged for by the HMO or CMP) apply again immediately.

(vi) If the enrollee fails to return to the HMO's or CMP's geographic area within 1 year from the date he or she left that area, the HMO or CMP must disenroll the beneficiary on the first day of the month following the anniversary of the date the enrollee left that area in accordance with paragraph (f)(1) of this section.

(g)Failure to convert to risk provisions of Medicare contract -

(1)Basis for disenrollment. A risk HMO or CMP must disenroll a nonrisk Medicareenrollee who refuses to convert to the risk provisions of the Medicare contract after CMS determines that all of the HMO's or CMP's nonrisk Medicareenrollees must convert.

(2)Advance notice requirement. At least 30 days before it gives CMSnotice of disenrollment, the HMO or CMP must give the enrollee written notice of the fact that failure to convert will result in disenrollment.

(h)Loss of entitlement to Medicare benefits -

(1)Loss of entitlement to Part A benefits. If an enrollee loses entitlement to benefits under Part A of Medicare but remains entitled to benefits under Part B, the enrollee automatically continues as a Medicareenrollee of the HMO or CMP and is entitled to receive and have payment made for Part B services, beginning with the month immediately following the last month of his or her entitlement to Part A benefits.

(2)Loss of entitlement to Part B benefits. If a Medicareenrollee loses entitlement to Part B benefits, the HMO or CMP must disenroll him or her as a Medicareenrollee effective with the month following the last month of entitlement to Part B benefits. However, the HMO or CMP may continue to enroll the individual under its regular plan if the individual so chooses.

(i)Death of the enrollee. Disenrollment is effective with the month following the month of death.

(j)Enrollee is not lawfully present in the United States. Disenrollment is effective the first day of the month following notice by CMS that the individual is ineligible in accordance with § 417.422(h).

[60 FR 45678, Sept. 1, 1995, as amended at 77 FR 22166, Apr. 12, 2012; 79 FR 29955, May 23, 2014; 80 FR 7958, Feb. 12, 2015]

42 CFR § 417.1 - Definitions.

• CFR

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§ 417.1 Definitions.

As used in this part, unless the context indicates otherwise -

Basic health services means health services described in § 417.101(a).

Community rating system means a system of fixing rates of payments for health services that meets the requirements of § 417.104(a)(3).

Comprehensive health services means as a minimum the following services which may be limited as to time and cost:

(1)Physician services (§ 417.101(a)(1));

(2) Outpatient services and inpatienthospital services (§ 417.101(a)(2));

(3) Medically necessary emergency health services (§ 417.101(a)(3)); and

(4) Diagnostic laboratory and diagnostic and therapeutic radiologic services (§ 417.101(a)(6)).

Direct service contract means a contract for the provision of basic or supplemental health services or both between an HMO and (1) a health professional other than a member of the staff of the HMO, or (2) an entity other than a medical group or an IPA.

Enrollee means an individual for whom an HMO, CMP, or HCPP assumes the responsibility, under a contract or agreement, for the furnishing of health care services on a prepaid basis.

Full-time student means a student who is enrolled for a sufficient number of credit hours in a semester or other academic term to enable the student to complete the course of study within not more than the number of semesters or other academic terms normally required to complete that course of study on a full-time basis at the school in which the student is enrolled.

Furnished, when used in connection with prepaid health care services, means services that are maid available to an enrollee either dierctly by, or under arrangements made by, the HMO, CMP, or HCPP.

Health maintenance organization (HMO) means a legal entity that provides or arranges for the provision of basic and supplemental health services to its enrollees in the manner prescribed by, is organized and operated in the manner prescribed by, and otherwise meets the requirements of, section 1301 of the PHS Act and the regulations in subparts B and C of this part.

Health professionals means physicians (doctors of medicine and doctors of osteopathy), dentists, nurses, podiatrists, optometrists, physicians' assistants, clinical psychologists, social workers, pharmacists, nutritionists, occupational therapists, physical therapists, and other professionals engaged in the delivery of health services who are licensed, practice under an institutional license, are certified, or practice under authority of the HMO, a medical group, individual practice association, or other authority consistent with State law.

Individual practice association (IPA) means a partnership, association, corporation, or other legal entity that delivers or arranges for the delivery of health services and which has entered into written services arrangement or arrangements with health professionals, a majority of whom are licensed to practice medicine or osteopathy. The written services arrangement must provide:

(1) That these health professionals will provide their professional services in accordance with a compensation arrangement established by the entity; and

(2) To the extent feasible, for the sharing by these health professionals of health (including medical) and other records, equipment, and professional, technical, and administrative staff.

Medical group means a partnership, association, corporation, or other group:

(1) That is composed of health professionals licensed to practice medicine or osteopathy and of such other licensed health professionals (including dentists, optometrists, and podiatrists) as are necessary for the provision of health services for which the group is responsible;

(2) A majority of the members of which are licensed to practice medicine or osteopathy; and

(3) The members of which:

(i) After the end of the 48 month period beginning after the month in which the HMO for which the group provides health services becomes a qualified HMO, as their principal professional activity (over 50 percent individually) engage in the coordinated practice of their profession and as a group responsibility have substantial responsibility (over 35 percent in the aggregate of their professional activity) for the delivery of health services to enrollees of an HMO;

(ii) Pool their income from practice as members of the group and distribute it among themselves according to a prearranged salary or drawing account or other similar plan unrelated to the provision of specific health services;

(iii) Share health (including medical) records and substantial portions of major equipment and of professional, technical, and administrative staff;

(iv) Establish an arrangement whereby an enrollee's enrollment status is not known to the health professional who provides health services to the enrollee.

Medical group members means (1) a health professional engaged as a partner, associate, or shareholder in the medical group, or (2) any other health professional employed by the group who may be designated as a medical group member by the medical group.

Medically underserved population means the population of an urban or rural area as described in Sec. 417.912(d).

Nonmetropolitan area means an area no part of which is within a standard metropolitan statistical area as designated by the Office of Management and Budget and which does not contain a city whose population exceeds 50,000 individuals.

Party in interest means: (1) Any director, officer, partner, or employee responsible for management or administration of an HMO, any person who is directly or indirectly the beneficial owner of more than 5 percent of the equity of the HMO, any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than 5 percent of the assets of the HMO, and, in the case of an HMO organized as a nonprofit corporation, an incorporator or member of the corporation under applicable State corporation law;

(2) Any entity in which a person described in paragraph (1):

(i) Is an officer or director;

(ii) Is a partner (if the entity is organized as a partnership);

(iii) Has directly or indirectly a beneficial interest of more than 5 percent of the equity; or

(iv) Has a mortgage, deed of trust, note, or other interest valuing more than 5 percent of the assets of such entity;

(3) Any spouse, child, or parent of an individual described in paragraph (1).

Policymaking body of an HMO means a board of directors, governing body, or other body of individuals that has the authority to establish policy for the HMO.

Qualified HMO means an HMO found by CMS to be qualified within the meaning of section 1310 of the PHS Act and subpart D of this part.

Rural area means any area not listed as a place having a population of 2,500 or more in Document #PC(1)A, “Number of Inhabitants,” Table VI, “Population of Places,” and not listed as an urbanized area in Table XI, “Population of Urbanized Areas” of the same document (1970 Census or most recent update of this document, Bureau of Census, U.S. Department of Commerce).

Secretary means the Secretary of Health and Human Services and any other officer or employee of the Department of Health and Human Services to whom the authority involved has been delegated.

Service area means a geographic area, defined through zip codes, census tracts, or other geographic measurements, that is the area, as determined by CMS, within which the HMO furnishes basic and supplemental health services and makes them available and accessible to all its enrollees in accordance with § 417.106(b). Facilities in which individuals are incarcerated are not included in the geographic service area of an HMO or CMP plan.

Significant business transaction means any business transaction or series of transactions during any one fiscal year of the HMO, the total value of which exceeds the lesser of $25,000 or 5 percent of the total operating expenses of the HMO.

Staff of the HMO means health professionals who are employees of the HMO and who -

(1) Provide services to HMOenrollees at an HMO facility subject to the staff policies and operational procedures of the HMO;

(2) Engage in the coordinated practice of their profession and provide to enrollees of the HMO the health services that the HMO has contracted to provide;

(3) Share medical and other records, equipment, and professional, technical, and administrative staff of the HMO; and

(4) Provide their professional services in accordance with a compensation arrangement, other than fee-for-service, established by the HMO. This arrangement may include, but is not limited to, fee-for-time, retainer or salary.

Subscriber means an enrollee who has entered into a contractual relationship with the HMO or who is responsible for making payments for basic health services (and contracted for supplemental health services) to the HMO or on whose behalf these payments are made.

Supplemental health services means the health services described in § 417.102(a).

Unusual or infrequently used health services means:

(1) Those health services that are projected to involve fewer than 1 percent of the encounters per year for the entire HMO enrollment, or,

(2) Those health services the provision of which, given the enrollment projection of the HMO and generally accepted staffing patterns, is projected will require less than 0.25 full time equivalent health professionals.

[45 FR 72528, Oct. 31, 1980, as amended at 47 FR 19338, May 5, 1982; 52 FR 22321, June 11, 1987. Redesignated at 52 FR 36746, Sept. 30, 1987. Redesignated and amended at 56 FR 51985, Oct. 17, 1991; 58 FR 38067, July 15, 1993; 60 FR 34887, July 5, 1995; 60 FR 45674, Sept. 1, 1995; 79 FR 29955, May 23, 2014]

Fraud Form Recipient's Name (First) (Last) Recipient's Gender Male Female Medicaid Number Recipient's Children - Names and Medicaid Numbers (Please fill out this field if you are reporting fraud by a parent of Medicaid recipient(s)) Recipient's Telephone Number (Please enter the phone number in XXX-XXX-XXXX format) Recipient's Address City State Zip Code Suspected Fraud You are able to report suspected fraud complaints anonymously.

But, if you would like the Medicaid Fraud Complaints Unit to contact you, please complete the fields below.

Name Telephone Number E-Mail Address Reporting Requirements Eligible entities are responsible for meeting specific querying and/or reporting requirements and must register with the NPDB in order to query or report to the NPDB.

Entities may qualify as more than one type of eligible entity.

In such cases, the entity must comply with all associated querying and reporting responsibilities.

Table E-1: Summary of Reporting Requirements Table E-1: Summary of Reporting Requirements, Part 1 Law Who Reports? What is Reported? Who is Reported? Title IV Medical malpractice payers, including hospitals and other health care entities that are self-insured Medical malpractice payments resulting from a written claim or judgment Practitioners State medical and dental boards Certain adverse licensure actions related to professional competence or conduct (Medical and dental boards that meet their reporting requirements for Section 1921, described in Part 2 of this table, will also meet their requirements to report under Title IV) Physicians and dentists Hospitals Other health care entities with formal peer review Certain adverse clinical privileges actions related to professional competence or conduct Physicians and dentists Other practitioners (optional) Professional societies with formal peer review Certain adverse professional society membership actions related to professional competence or conduct Physicians and dentists Other practitioners (optional) DEA DEA controlled-substance registration actions* Practitioners OIG Exclusions from participation in Medicare, Medicaid, and other federal health care programs* Practitioners * This information is reported to the NPDB under Title IV based on a memorandum of understanding.

Table E-1: Summary of Reporting Requirements, Part 2 Law Who Reports? What is Reported? Who is Reported? Section 1921 Peer review organizations Negative actions or findings by peer review organizations Practitioners Private accreditation organizations Negative actions or findings by private accreditation organizations Entities, providers, and suppliers State licensing and certification authorities State licensure and certification actions Practitioners, entities, providers, and suppliers State law enforcement agencies* State Medicaid fraud control units* State agencies administering or supervising the administration of a state health care program* State prosecutors Exclusions from participation in a state health care program Health care-related civil judgments in state court Health care-related state criminal convictions Other adjudicated actions or decisions Practitioners, providers, and suppliers Section 1128E Federal agencies Federal prosecutors Health plans Federal licensure and certification actions** Health care-related civil judgments in federal or state court Health care-related criminal convictions in federal or state court** Exclusions from participation in a federal health care program** Other adjudicated actions or decisions Practitioners, providers, and suppliers * NPDB regulations define "state law or fraud enforcement agency" as including but not limited to these entities.

** Reported only by federal agencies.

The reporting requirements summarized in Table E-1 are described in greater detail in this chapter.

As shown in the table, each of the three major statutes governing NPDB operations has its own reporting requirements.

In some instances, actions must be reported based on memorandums of understanding.

In certain cases, requirements may exist under more than one statute, or under both a statute and a memorandum of understanding.

For example, as discussed in Chapter B: Eligible Entities, the Drug Enforcement Administration's (DEA's) controlled-substance registration actions are reported to the NPDB under Title IV based on a memorandum of understanding; the Department of Health and Human Services (HHS) Office of Inspector General's (OIG's) exclusions from Medicare, Medicaid, and other federal health care programs are reported to the NPDB under Title IV based on an interagency agreement.

Both DEA and OIG actions also must be reported to the NPDB under Section 1128E.

Terminology Differences An action must be reported to the NPDB based on whether it satisfies NPDB reporting requirements and not based on the name affixed to the action by a reporting entity.

For example, whether an administrative fine is reportable to the NPDB depends upon whether the fine meets NPDB reporting requirements, not on the name affixed to the fine.

A suspension or restriction of clinical privileges is reportable if it meets reporting criteria, whether the suspension or restriction is called summary, immediate, emergency, precautionary, or any other term.

Time Frame for Reporting Eligible entities must report medical malpractice payments and other required actions to the NPDB within 30 calendar days of the date the action was taken or the payment was made.

The time frame for reporting each type of action described in Table E-1 is summarized in Table E-2.

Table E-2: Time Frame for Reporting Types of Actions that Must Be Reported When Information Must be Reported Medical malpractice payments Certain adverse licensure actions related to professional competence or conduct (reported under Title IV) Certain adverse clinical privileges actions related to professional competence or conduct Certain adverse professional society membership actions related to professional competence or conduct DEA controlled-substance registration actions on practitioners (reported under Title IV) Exclusions from participation in Medicare, Medicaid, and other federal health care programs (reported under Title IV) Within 30 days of the date the action was taken or the payment was issued, beginning with actions occurring on or after September 1, 1990 Negative actions or findings taken by peer review organizations Negative actions or findings taken by private accreditation organizations Within 30 days of the date the action was taken, beginning with actions occurring on or after January 1, 1992 State licensure and certification actions Federal licensure and certification actions Health care-related criminal convictions in federal or state court Health care-related civil judgments in federal or state court Exclusions from participation in a federal or state health care program.

Other adjudicated actions or decisions Within 30 days of the date the action was taken, beginning with actions occurring on or after August 21, 1996 The NPDB cannot accept reports with a date of payment or a date of action prior to September 1, 1990, with the exception of Medicare and Medicaid exclusions submitted by the OIG.

If an eligible entity discovers documentation of medical malpractice payments, adverse actions, or judgments or convictions that the eligible entity had not reported to the NPDB, the entity must promptly submit the related report(s).

All required reports must be filed with the NPDB regardless of whether they are late.

Entities are not excused from reporting simply because they missed a reporting deadline.

The Secretary of HHS will conduct an investigation if there is reason to believe an entity substantially failed to report required medical malpractice payments or adverse actions.

Entities have the opportunity to correct the noncompliance (see "Sanctions for Failing to Report" to the NPDB in the sections discussing the reporting requirement for each type of action).

Deceased Practitioners One of the principal objectives of the NPDB is to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without the disclosure or discovery of their previous damaging or incompetent performance.

Reports concerning deceased practitioners must be submitted to the NPDB because a fraudulent practitioner could assume the identity of a deceased practitioner.

When submitting a report on a deceased practitioner, indicate that the practitioner is deceased in the appropriate data field.

Report Retention Information reported to the NPDB is maintained permanently in the NPDB, unless it is corrected or voided from the NPDB by the reporting entity or by the NPDB as a result of the Dispute Resolution process.

Civil Liability Protection The immunity provisions in Title IV, Section 1921, and Section 1128E protect individuals, entities, and their authorized agents from being held liable in civil actions for reports made to the NPDB unless they have actual knowledge of falsity of the information contained in the report.

These provisions provide the same immunity to HHS in maintaining the NPDB.

Official Language The NPDB's official language is English.

All reports must be submitted in English.

Files submitted in any other language or containing non-alphanumeric characters (e.g., tildes, accents, umlauts) are not accepted.

To search the Office of Inspector General's (OIG) national exclusions database, use this link: To search the System for Award Management (SAM) database for entities that have been excluded from contracting with the federal government, use this link: Any person or entity is prohibited from participation in Medicaid if excluded, to include: employment directly or indirectly, contracting, or ownership.

Doing so while excluded is violation and is considered a crime under LA R.S. 14:126.3.1 (2009).

Although the stated period of time for the exclusion may have passed, this does not imply reinstatement.

After the exclusion period has ended the excluded party may submit a written application for reinstatement.

Resumption of participation in the Medicaid Program following exclusion is neither automatic nor a right.

Applications for reinstatement will be reviewed by the state and given fair and impartial consideration.

La.-R.S. 46:437.13 (C) (2008).

Providers that are terminated for cause are prohibited from participation for a minimum of 90 of days from the effective date.

Once the minimum period has elapsed, the provider must re-enroll.

Resumption of participation in the Medicaid Program following a termination for cause is neither automatic nor a right.

Employers must use the DSW registry to determine if there is a finding that a prospective hire has abused or neglected an individual being supported, or misappropriated the individual’s property or funds.

If there is such a finding on the registry, the prospective employee shall not be hired.

The provider shall check the registry every six months to determine if any currently employed direct service worker or trainee has been placed on the registry with a finding that he/she has abused or neglected an individual being supported or misappropriated the individual’s property or funds.

Louisiana Department of Health announces new Medicaid Executive Director September 09, 2021 Patrick Gillies has joined the Louisiana Department of Health as the new Medicaid Executive Director.

Gillies has more than 20 years of experience in healthcare administration on both the state and federal levels.

He most recently worked as an independent consultant assisting organizations with operations including healthcare systems operations, Medicare and Medicaid.

In previous roles, Gillies worked with organizations to support their participation in the 340B Drug Discount Program and provided leadership and accountability for the Medicaid line of business for three Regional Care Collaborative Organizations (RCCOs) set up through the Colorado Department of Health Care Policy and Financing's Accountable Care Collaborative (ACC).

He has also served as a regional administrator for Health Resources & Services Administration (HRSA) and as the Director of Community Health for the Texas Department of State Health Services.

Gillies holds a Master of Public Administration in Health Policy & Administration from Texas Tech University.

Notice.

Notice.

If CMS decides to terminate a contract it gives notice of the termination as follows: (1) Termination of contract by CMS.

(i) CMS notifies the MA organization in writing at least 45 calendar days before the intended date of the termination.

(ii) The MA organization notifies its Medicare enrollees of the termination by mail at least 30 calendar days before the effective date of the termination.

(iii) The MA organization notifies the general public of the termination at least 30 calendar days before the effective date of the termination by releasing a press statement to news media serving the affected community or county and posting the press statement prominently on the organization's Web site.

(iv) In the event that CMS issues a termination notice to an MA organization on or before August 1 with an effective date of the following December 31, the MA organization must issue notification to its Medicare enrollees at least 90 days prior to the effective date of the termination.

(2) Immediate termination of contract by CMS.

(i) The procedures specified in paragraph (b)(1) of this section do not apply if - (A) CMS determines that a delay in termination, resulting from compliance with the procedures provided in this part prior to termination, would pose an imminent and serious risk to the health of the individuals enrolled with the MA organization; or (B) The MA organization experiences financial difficulties so severe that its ability to make necessary health services available is impaired to the point of posing an imminent and serious risk to the health of its enrollees, or otherwise fails to make services available to the extent that such a risk to health exists; or (C) The contract is being terminated based on the grounds specified in paragraph (a)(4)(i) of this section.

(ii) CMS notifies the MA organization in writing that its contract will be terminated on a date specified by CMS.

If a termination is effective in the middle of a month, CMS has the right to recover the prorated share of the capitation payments made to the MA organization covering the period of the month following the contract termination.

(iii) CMS notifies the MA organization's Medicare enrollees in writing of CMS's decision to terminate the MA organization's contract.

This notice occurs no later than 30 days after CMS notifies the plan of its decision to terminate the MA contract.

CMS simultaneously informs the Medicare enrollees of alternative options for obtaining Medicare services, including alternative MA organizations in a similar geographic area and original Medicare.

(iv) CMS notifies the general public of the termination no later than 30 days after notifying the plan of CMS's decision to terminate the MA contract.

This notice is published in one or more newspapers of general circulation in each community or county located in the MA organization's service area.

42 CFR § 422.510 Scoping language Termination by CMS.

CMS may at any time terminate a contract if CMS determines that the MA organization meets any of the following: (1) Has failed substantially to carry out the contract.

(2) Is carrying out the contract in a manner that is inconsistent with the efficient and effective administration of this part.

(3) No longer substantially meets the applicable conditions of this part.

(4) CMS may make a determination under paragraph (a)(1), (2), or (3) of this section if the MA organization has had one or more of the following occur: (i) Based on creditable evidence, has committed or participated in false, fraudulent or abusive activities affecting the Medicare, Medicaid or other State or Federal health care programs, including submission of false or fraudulent data.

(ii) Substantially failed to comply with the requirements in subpart M of this part relating to grievances and appeals.

(iii) Failed to provide CMS with valid data as required under § 422.310. (iv) Failed to implement an acceptable quality assessment and performance improvement program as required under subpart D of this part.

(v) Substantially failed to comply with the prompt payment requirements in § 422.520. (vi) Substantially failed to comply with the service access requirements in § 422.112 or § 422.114. (vii) Failed to comply with the requirements of § 422.208 regarding physician incentive plans.

(viii) Substantially fails to comply with the requirements in subpart V of this part.

(ix) Failed to comply with the regulatory requirements contained in this part or part 423 of this chapter or both.

(x) Failed to meet CMS performance requirements in carrying out the regulatory requirements contained in this part or part 423 of this chapter or both.

(xi) Achieves a Part C summary plan rating of less than 3 stars for 3 consecutive contract years.

Plan ratings issued by CMS before September 1, 2012 are not included in the calculation of the 3-year period.

(xii) Has failed to report MLR data in a timely and accurate manner in accordance with § 422.2460 or that any MLR data required by this subpart is found to be materially incorrect or fraudulent.

(xiii) Fails to meet the preclusion list requirements in accordance with § 422.222 and 422.224. (xiv) The MA organization has committed any of the acts in § 422.752(a) that support the imposition of intermediate sanctions or civil money penalties under subpart O of this part.

(xv) Following the issuance of a notice to the MA organization no later than August 1, CMS must terminate, effective December 31 of the same year, an individual MA plan if that plan does not have a sufficient number of enrollees to establish that it is a viable independent plan option.

The Mental Health Parity and Addiction Equity Act (MHPAEA) The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that prevents health care service plans from imposing more restrictive benefit limitations on mental health and substance use disorder (MH/SUD) benefits than on medical/surgical coverage.

Health plans must ensure that financial requirements (such as co-pays and deductibles) and treatment limitations that apply to MH/SUD benefits are no more restrictive than the predominant requirements or limitations applied to medical and surgical benefits.

Louisiana Medicaid will complete a compliance review of all services by October 2, 2017.

This initiative will ensure Louisiana Medicaid recipients receiving Medicaid and CHIP services receive equal access to physical and behavioral health care.

Legislative History 1996: Mental Health Parity Act of 1996 (MHPA) Required certain commercial group health coverage have parity in aggregate lifetime and dollar limits 2008: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) Added substance use disorder services and required parity in treatment/financial limitations 2013: Final mental health parity rules for commercial plans 2016: Final mental health parity rules for Medicaid and CHIP managed care organizations (MCOs) Classifications Louisiana will place each Medicaid service in the following four classifications required in parity analysis: Inpatient Outpatient Emergency Care Prescription Drugs Treatment Limitations to be Analyzed Quantitative Treatment Limitations: Limits on benefits based on the frequency of treatment; examples include: Number of visits Days of coverage Days in a waiting period, or Other similar limits on the scope or duration of treatment Non-Quantitative Treatment Limitations: No “hard limits” but limit the ability of a person to receive a certain service or level of services; examples include: Prior Authorization Processes Concurrent Review “Fail First” Policies Additional Resources Louisiana Parity Report LDH Mental Health Parity FAQ LDH Parity 101 Louisiana Department of Insurance Parity Website MHPAEA Factsheet Mental Health Parity and Addiction Equity Act of 2008 Department of Labor's Mental Health Parity FAQ 120.6 - Continuity of Care (Rev.

77, Issued: 10-28-05, Effective Date: 10-28-05) Continuity of care refers to the continuous flow of care in a timely and appropriate manner.

Continuity includes: • Linkages between primary and specialty care; • Coordination among specialists; • Appropriate combinations of prescribed medications; • Coordinated use of ancillary services; • Appropriate discharge planning; and • Timely placement at different levels of care including hospital, skilled nursing and home health care.

(42 CFR 417.407(f), 42 CFR 417.122(b)) In the case of insolvency the HMO must continue to provide benefits to all enrollees for the duration of the contract period for which payment was made.

120.7 - Recordkeeping (Rev.

77, Issued: 10-28-05, Effective Date: 10-28-05) 130.8 - Appeal and Anti-Discrimination Rights (Rev.

77, Issued: 10-28-05, Effective Date: 10-28-05) A Medicare cost plan may not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive.

Furthermore, the Medicare cost plan must inform individuals that complaints concerning noncompliance with the advance directive requirements may be filed with the State Survey and Certification Agency .

Can providers request a face-to-face visit when we have a problem? Yes.

Call Provider Relations at 1-800-473-2783 to request a field analyst visit.

To see who the field analyst is for your area, use the Provider Support link 6.

For recipients in Medicare HMOs that receive pharmacy services, can providers collect the Medicaid pharmacy co-payment? Yes.

7.

Do providers have to accept the Medicaid card for prior services if the recipient did not inform us of their Medicaid coverage at the time of services? No.

If at the time of service the patient did not inform you of their Medicaid coverage, they were treated as a private pay patient, you do not have to go back and accept the Medicaid card for those prior services.

8.

Who should be contacted if a provider is retiring? The Gainwell Technologies Provider Enrollment Unit must be notified in writing of the retirement date.

The address is P.O. Box 80159, Baton Rouge, LA 70898-0159.

The phone number is (225)216-6370.

9.

If providers bill Medicaid for accident-related services, do they have to use the annotation stamp on our documentation? Yes.

The annotation stamp should be on all accident-related documentation requested by third parties, including attorneys, insurance companies, etc.. 10.

What if a Lock-In recipient tries to circumvent the program by going to the ER for services? Report the recipient to the Lock-In Unit at DHH so they can educate the recipient.

11.

Does the State print a complete list of error codes for provider use? Yes; this code listing can be found by accessing the Forms/Files/User Manuals page of this website, under the Online Forms or Files section of that page, and clicking the link titled LA Medicaid/HIPAA Error Code Crosswalk.

Or by clicking here.

12.

If providers do not want to continue accepting Medicaid from an existing patient, can they stop seeing the patient? If a provider does not want to continue accepting Medicaid/Bayou Health plan from an existing patient, they must notify the recipient before they want to stop seeing the patient.

The patient can either continue seeing the provider as a private pay patient or they may find another provider to accept their Medicaid/Bayou Health plan card.

You must notify the recipient first and give them ample time to find another provider that will accept their Medicaid/Bayou Health plan card.

Ample time is considered at least two (2) months prior to discontinuing services.

EPSDT providers must call the EPSDT contractor to have that recipient unlinked from their caseload.

Louisiana Behavioral Health Advisory Council History of Mental Health Planning and Advisory Councils With Public Law 102-321, passed in 1992, the federal government dictated mental health planning as a condition of receipt of federal mental health grant funds, and has mandated participation in the planning process by stakeholder groups, including mental health consumers, parents of children with serious emotional or behavioral disturbances and family members.

The Louisiana Behavioral Health Advisory Council is Louisiana's planning organization.

The quarterly meetings are held on the first Monday of the month, beginning with the second month of the year (February, May, August, November) at 9:30 am.

Please contact Melanie Roberts for meeting location.

Additional Resources FY22-23 Block Grant Application- Draft FY21 Mini Block Grant Application-Draft 2020-2021 Louisiana Combined Behavioral Health Block Grant Application 2018-2019 Louisiana Combined Behavioral Health Block Grant Application 2016-17 Louisiana CMHS and SAPT Combined Block Grant Application Click here to submit comments related to the 2016-17 Block Grant Application/Plan 2014 Louisiana CMHS and SAPT Combined Block Grant Application Mailing Address P.O. Box 4049 Baton Rouge, LA 70821-4049 Contact Information Government Sites Center for Medicaid and Medicare Services (CMS) CMS – Payment Error Rate Measurement (PERM) DHH Office of Aging and Adult Services DHH Division of Fiscal Management Page Louisiana Board of Pharmacy Louisiana Medicaid News Louisiana Medicaid Program Home Page (BHSF) Louisiana State Board of Dentistry Louisiana State Board of Medical Examiners Louisiana State Board of Optometry Examiners Associations American Medical Association Louisiana Dental Association Louisiana Nursing Home Association Louisiana Osteopathic Medical Association Louisiana State Medical Society Optometry Association of Louisiana Vendors Emdeon Business Services Healthcare Data Exchange Medifax Other InfoLouisiana Language Tools - Translator Website Louisiana Drug and Poison Information Center Provider Synergies Washington Publishing Company WebMD Healthy Site Melanie Roberts, MS 225.892.2329 melanie.roberts@la.gov Mailing Address P.O. Box 4049 Baton Rouge, LA 70821-4049 Contact Information Melanie Roberts, MS 225.892.2329 melanie.roberts@la.gov Staff Catherine Peay Block Grant State Planner 225.342.7945 catherine.peay@la.gov Melanie Roberts LBHAC Liaison 225.892.2329 Melanie.Roberts@LA.GOV P.O Box 40517 Baton Rouge, LA 70835 Anthony Germade LBHAC Chair 225.291.6262 agermade@namilouisiana.org NAMI Louisiana, National Alliance on Mental Illness 307 France Street, Ste.

A Baton Rouge, LA 70802 Ericka Poole LBHAC Vice Chair ericka@redstickmom.com Katelyn Burns LBHAC Support Staff 225.291.6262 kburns@namilouisiana.org NAMI Louisiana, National Alliance on Mental Illness 307 France Street, Ste.

A Baton Rouge, LA 70802 Bienville Building ▪ 628 N.

Fourth St.

▪ P.O. Box 91030 ▪ Baton Rouge, Louisiana 70821-9030 Phone: (888) 342-6207 ▪ Fax: (225) 342-9508 ▪ An Equal Opportunity Employer Recipient Eligibility Verification System (REVS) 1-800-776-6323 or (225) 216-7387 *Note: All telephone numbers (except MEVS and REVS) are in operation from 8 a.m. until 5 p.m. Monday through Friday excluding holidays.

DHH Medicaid Telephone Numbers M E M O R A N D U M DATE: September 3, 2021 TO: All Louisiana Medicaid Providers FROM: Michael Boutte, Interim Medicaid Director SUBJECT: August 2021 Hurricane Ida Information for Medicaid Pharmacy On August 26, 2021, Governor John Bel Edwards declared a state of emergency for Hurricane Ida, as significant impact to the state was expected.

Due to continued effects of the storm, pharmacy claim edits will be adjusted as follows in these parishes: Ascension, Assumption, East Baton Rouge, East Feliciana, Iberia, Iberville, Jefferson, Lafourche, Livingston, Orleans, Plaquemines, Pointe Coupee, St.

Bernard, St.

Charles, St.

Helena, St.

James, St.

John the Baptist, St.

Martin, St.

Mary, St.

Tammany, Tangipahoa, Terrebonne, Washington, West Baton Rouge and West Feliciana.

Pharmacists Authority to Dispense Prescriptions in an Emergency The Louisiana Board of Pharmacy reminded pharmacists about Section 519 of the Board’s rules, titled State of Emergency that has been activated and is now in effect.

This rule is automatically activated whenever the Governor of Louisiana declares and/or renews a state of emergency for some or all of the parishes of Louisiana.

The rule states, in part: "1.

A pharmacist may work in the affected parish(es) and may dispense a one-time emergency prescription of up to a thirty day supply of a prescribed medication if: (a) in the pharmacist's professional opinion the medication is essential to the maintenance of life or to the continuation of therapy, and (b) the pharmacist makes a good faith effort to reduce the information to a written prescription marked "Emergency Prescription", then file and maintain the prescription as required by law." The above is noted to instruct pharmacists of prescription regulations during a time of emergency.

This applies to all patients, regardless of whether they have public or private health insurance coverage or are uninsured.

Reimbursement for the prescription is not addressed by this regulation.

Procedures for Emergency Prescriptions Claims for Medicaid Recipients The early refill edit has been changed from a denial edit to an educational edit for Fee for Service (FFS) and the managed care organizations (MCOs) pharmacy claims in these parishes through September 30, 2021: Ascension, Assumption, East Baton Rouge, East Feliciana, Iberia, Iberville, Jefferson, Lafourche, Livingston, Orleans, Plaquemines, Pointe Coupee, St.

John Bel Edwards GOVERNOR Dr.

Courtney N.

Phillips SECRETARY SECRETARY State of Louisiana Louisiana Department of Health Bureau of Health Services Financing August 2021 Hurricane Ida Information for Medicaid Pharmacy September 3, 2021 Page 2 Bernard, St.

Charles, St.

Helena, St.

James, St.

John the Baptist, St.

Martin, St.

Mary, St.

Tammany, Tangipahoa, Terrebonne, Washington, West Baton Rouge and West Feliciana.

All existing prior authorizations for pharmacy claims for recipients residing in the above parishes will be extended through October 31, 2021.

Follow this link for other resources including FAQs for providers that contains directions for expedited provider enrollment for FFS and the MCOs: If you have questions about the content of this memo, you may contact the FFS pharmacy help desk by phone at (800) 437-9101.

If you have questions about pharmacy claims billing, you may contact the appropriate plan at their pharmacy help desk listed in the chart below.

Healthcare Provider Pharmacy Help Desk Pharmacy Help Desk Phone Number Aetna CVS Health (855) 364-2977 AmeriHealth Caritas PerformRx (800) 684-5502 Fee for Service Gainwell Technologies (800) 648-0790 Healthy Blue CVS (833) 236-6194 Louisiana Healthcare Connections CVS Caremark (800) 311-0543 UnitedHealthcare Optum Rx (866) 328-3108 Eligibility and Drug Utilization Data for Medicaid Recipients Pharmacists may access the Louisiana Medicaid website at This website is a useful tool to access information regarding recipients, prescribing provider numbers and clinical data.

To gain access to the website, providers should follow directions on the website.

Providers should obtain a log-in ID and password.

Detailed instructions are at then “Provider web account registration instructions” or at this link: Providers are able to access the Medicaid Eligibility Verification System (MEVS) to verify recipient eligibility.

Go to Provider Log-In on enter Medicaid ID or NPI then enter Log-In ID and password.

Go to Medicaid Eligibility Verification System, and then enter the recipient’s name and date of birth or social security number.

Providers may access recipient pharmacy claim history for both FFS and MCOs through the electronic Clinical Data Inquiry (e-CDI).

Go to Provider Log-In on enter Medicaid ID or NPI then enter Log-In ID and password.

Go to Electronic Clinical Data Inquiry, enter recipient ID and date of birth, find recipient, then clinical drug inquiry.

Your continued cooperation and support of the Louisiana Medicaid Program efforts to coordinate care and improve health are greatly appreciated.

August 2021 Hurricane Ida Information for Medicaid Pharmacy September 3, 2021 Page 3 MB/MBW/ESF c: Marcus Bachhuber Healthy Louisiana Plans Melwyn B.

Wendt Gainwe Remind yourself and others that its normal to have many different feelings as well as “good days” and “bad days” as a natural part of recovery.

Seek assistance from a health care professional if your distress remains high after several weeks, you are having persistent trouble functioning at work or home, or thinking about hurting yourself or someone else.

Helping Children See also: Supporting Homebound Children During COVID-19 from the Center for the Study of Traumatic Stress Louisiana Psychiatric Medical Association Cathy Thompson, Executive Director lpmastaff@lpma.net 1905 W.

Thomas St., Ste.

D #132, Hammond, LA 70401 Phone: (225) 761-3718 Fax: (225) 761-3719 Ethical Challenges in the Treatment of Anxiety Jarrod A.

Marks, M.D., Samuel Rosenblatt, B.A., James L.

Knoll IV, M.D. Anxiety is sometimes referred to as the “fever”of psychiatry (1).

The state of anxiety is very common and is perhaps one of the most nonspecific symptoms in psychiatry.

A great deal of psychiatric and philosophical theory has emerged around anxiety as a feeling state that is normal and perhaps even adaptive.

Søren Kierkegaard famously described anxiety as being the “dizziness of freedom”(2) that living beings with the ability to choose inevitably feel.

On the other hand, pathological disorders—collectively termed in the DSM-5as anxiety disorders—are some of the most commonly di- agnosed in psychiatry.

It is estimated that one in four people meet the diagnostic criteria for at least one anxiety disorder, with a 12-month prevalence rate of 17.7% (3).

Unique challenges in the evaluation and treatment of anxiety give rise to various ethical problems.

This column illustrates several ethical concepts, including various aspects of informed consent, the boundaries of treatment, confi- dentiality, and the conceptualization of treatment itself through several case vignettes.

First, we address the anxiety formulation that will resurface in the vignettes.

The Anxiety Formulation Anxiety is a universal human phenomenon.

It represents a feeling state that often includes unpleasant apprehension along with various autonomic symptoms, including palpita- tions or increased heart rate.

The DSM-5distinguishes be- tween fear and anxiety, which can also overlap.

Whereas fear is a response to a real or perceived imminent threat, anxiety is the anticipation of some future threat.

The most important distinction that a psychiatrist must make when evaluating a patient experiencing anxiety is whether the anxiety is part of a disease process or part of the normative range of human experience.

Anxiety disorders differ from developmentally normative fear or anxiety in that the former are “excessive or persisting beyond devel- opmentally appropriate periods”(4).

Further, distinguishing normative from excessive anxiety may require exploration of cultural factors.

The search for the existence of a disease process is particularly important in the Hippocratic tradi- tion of medicine, which seeks to treat diseases and manage symptoms conservatively.

As the following vignettes illustrate, the distinction be- tween management of symptoms and treatment of disease process has an important effect on the ultimate prognosis and course of illness.

For example, if a patient’s anxiety is caused primarily by a psychotic illness, management of anxiety as an isolated symptom will lead to a different clin- ical outcome than would treatment focused on the psychotic illness itself.

From an ethical perspective, distinguishing between isolated symptoms and disease process will affect the informed consent process, specifically relating to a complete discussion of the patient’s condition and its prob- able course.

The explanatory model discussed with the pa- tient will affect the patient’s treatment decisions.

For example, a patient might be inclined to accept pharmaco- logical treatment for anxiety related to a chronic illness that is likely to persist or worsen without disease-modifying treat- ment.

However, the same patient may choose to engage in psychotherapy or no treatment at all for anxiety related to the stresses of life, with no apparent underlying disease process.

Distinguishing pathological from normative-range anxi- ety can be challenging.

Within the realm of pathological anxiety, the discerning clinician must explore whether the anxiety is due to a general medical condition (e.g., hyper- thyroidism), whether it is a primary anxiety disorder (such as a phobia), or whether it is a symptom of an underlying mood or psychotic illness.

To make matters more compli- cated, all three types of anxiety can co-occur in various permutations.

For example, anxiety due to posttraumatic stress disorder may be exacerbated by thyroid disease.

Thus, careful attention must be given to teasing out the causes and temporal relationships of anxiety symptoms.

The clinician must keep in mind that anxiety disorders are often highly comorbid conditions.

Differentiation and diagnosis often depend upon taking a careful general medical and psychi- atric history in addition to delineating “the types of situa- tions that are feared or avoided and the content of the associated thoughts or beliefs”(4).

Table 1 gives a nonexhaustive list of the most common types of anxiety seen in psychiatric practice.

As we discuss later, identifying anxiety as part of a psychotic or affective illness is important clinically and ethically as part of the informed consent process.

ETHICS COMMENTARY 212 focus.psychiatryonline.org Focus Vol.

19, No.

2, Spring 2021TABLE 1.

Common types of anxiety seen in psychiatric practicea Anxiety type Examples Anxiety illness due to another medical condition Thyroid disease, pheochromocytoma Personality trait Anxious, avoidant, dependent Mood illness related Unipolar depression, bipolar illness Psychotic illness related Schizophrenia, depression with psychotic features Primary anxiety illness Posttraumatic stress disorder, specific phobia Existential anxiety Fear of death and impermanence aAdapted from Ghaemi (1, pp.

273–280).We write this column in the midst of a global pandemic.

Symptoms of anxiety and depression have increased con- siderably since the COVID-19 pandemic began (5).

Many people are experiencing unprecedented levels of loss, grief, and constraints in life—and bearing it all while feeling more alone and isolated than ever before.

We would expect to see a rise in existential anxiety dur- ing these times, with an increased awareness (or new aware- ness) of mortality.

For some patients, things that used to cause anxiety, such as college coursework and tests, are now more anxiety provoking in new virtual formats.

At the same time, illnesses such as schizophrenia and bipolar disorder are newly emerging in patients.

Patients who have lived with these disorders since before the pandemic may see worse- ning symptoms from added stress and isolation.

During this era of COVID-19, clinicians must continue to use their diag- nostic acumen to consider all possible causes of anxiety.

Case 1, Part 1 Mr.

C is a 23-year-old man who presents to a resident psy- chiatry clinic during the COVID-19 pandemic with a chief complaint of overwhelming anxiety.

Boundary crossings represent devia- tions from the standard frame of treatment that are performed with a therapeutic purpose and are meant to be helpful to the patient.

Boundary violations are de- viations from the standard therapeutic frame that are harmful to the patient and may be meant to benefit the clinician (13).

Visiting a dog shelter with the patient while attempting to preserve the other elements of the treatment frame is meant to help treat the patient and alleviate suffering.

Social dining, intimate physical contact, and disclosing personal problems all lack therapeutic value and risk exploitation of the patient for the therapist’s benefit.

AUTHOR AND ARTICLE INFORMATION Department of Psychiatry, SUNY Upstate Medical University, Syracuse (Marks, Rosenblatt, Knoll).

Send correspondence to Dr.

Marks (jarrodamarks@gmail.com). The authors report no financial relationships with commercial interests.

Focus 2021; 00:1–5; doi: 10.1176/appi.focus.202Contact APA's Department of Government Relations Team For more information on how your state can get involved in advancing mental health parity, please contact APA Director of Government Relations Erin Berry Philp at ephilp@psych.org Top Strengthen Your Case with Federal Court Findings There are a number of patient and provider guides for navigating the appeals process that contain complimentary guidance, much of which aligns with the considerations below.

The following proposed appeals strategy builds on current guidance by offering language and approaches for incorporating Wit case findings as a motivating factor for insurers to reconsider care denial decisions.

Dr.

Plakun’s 4 Tools to Maximize Appeal Success Appealing Treatment and Reimbursement Denials (American Psychiatric Association) A Patient’s Guide to Navigating the Insurance Appeals Process (Patient Advocate Foundation) What to Do if You’re Denied Care by Your Insurance (National Alliance on Mental Illness) Appeal Strategy Concepts Apply the following strategies when preparing for and responding to excessively restrictive claims denials.

Examine your organization’s claims denial data to identify where insurers’ reasons for denials are at odds with one or more of the eight principles stipulated by the court in the Wit case and how often appeals are granted or denied.

This analysis will enable you to execute an appeal strategy that is informed by the challenges your patient population faces and provides a mechanism for continuous quality improvement.

Pay close attention to trends in populations such as children, adolescents, young adults, pregnant/postpartum women and those with co-occurring or underlying conditions, as these groups may be at increased risk for denial of necessary care.

If you are not currently analyzing this type of data, it should not prevent you from implementing the rest of the appeal strategies; however, you may consider denial and appeal data analysis as a longer-term goal for your organization.

Understand each of your common insurer’s utilization review criteria.

As noted previously, although the findings in the Wit case only involved one insurer, the standard of care concepts should be applied broadly across all behavioral health insurers.

Keep in mind that even if the guidelines are compliant on paper, they must also be compliant as applied in operations.

Patient Advocate Foundation (no date).

A Patient’s Guide to Navigating the Insurance Appeals Process.

Retrieved from 19 National Alliance on Mental Illness (no date).

What to Do If You’re Denied Care by Your Insurance.

Retrieved from Find-Support/Living-with-a-Mental-Health-Condition/Understanding-Health-Insurance/What-to-Do-If-You-re-Denied-Care-By-Your-Insura If you receive a denial from your insurance company for mental health treatment that you and your treating clinician believe is medically necessary, there are four important tools to maximize the chances for success in an appeal: 

Insist on access to the written criteria used to determine medical necessity for the treatment you are seeking and to which ones they say your case doesn’t meet.

Your voice and the voices of those supporting your treatment matter.

You, your family members, and your treating and referring clinicians can write letters explaining your need for treatment based, whenever possible, on challenging the specific reasons for denial.

The insurance agent who sold the policy, a benefits manager (if your insurance plan has one), or your state’s insurance review board (if one exists) may also be able to offer assistance.

Whatever actions you take, fully document all interactions you have with your insurance company or the reviewing agency—including hold times, referrals to other phone numbers, and the like.

Show that you have the will and the wherewithal to stand up for your rights.

Research and other benchmarks to back up claims of medical necessity are helpful in the appeals process.

There are instruments to guide level-of-care decisions using objective methodology, such as the Level of Care Utilization System (LOCUS) developed by the American Association of Community Psychiatrists and used in 26 states and in multiple countries.

In addition, the American Psychiatric Association (APA) Clinical Practice Guidelines often lay out evidence-based components of treatment for many disorders.

Both methodologies can provide an objective frame of reference–in fact, many insurance companies and reviewing agencies claim to use both in developing their own criteria.

Current peer-reviewed research can also anchor appeals to an evidence base for specific kinds of treatment.

Riggs has organized a large body of research supporting the kind of longer-term, residential treatment we offer, available online: Citing resources like these can help in building a case for treatment that you and your treating clinician believe to be medically necessary.

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that the quantitative (e.g., number of office visits, or inpatient days) and non-quantitative (e.g., hurdles like prior authorization or concurrent review) limits applied to access to mental health care be comparable to those applied to medical coverage.

For example, if a health insurance company says someone with a mental health issue cannot receive treatment unless he stops drinking, but continues to cover treatment for someone with diabetes who is not following his diet, the policy is likely out of compliance with the parity law.

Similarly, if an “intermediate” level of care like residential treatment is excluded except for those meeting criteria for acute inpatient treatment, but intermediate levels of care are covered for medical issues, the policy is likely out of compliance with the parity law.

If you believe a denial does not comply with the parity law, raise this concern in the appeal.

You may wish to speak with an attorney familiar with parity law violations or your State Attorney General’s Office.

Plakun’s 4 Tools to Maximize Appeal Success Reference Judge Joseph Spero’s verdict in the Wit v.

UBH/Optum case and what the verdict says about restrictive access to care criteria that focus treatment on the limited goal of crisis stabilization • “Having reviewed all of the versions of the Guidelines that Plaintiffs challenge in this case and considered the testimony of the witnesses addressing the meaning of the Guidelines, the Court finds, by a preponderance of the evidence, that in every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.” • “[I]n each version of the Guidelines at issue in this case the defect is pervasive and results in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.” • Effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms.

• Effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care.

• Patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective– the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective.

Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions.

• When there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care.

• Effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration.

• Appropriate duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment.

• The unique needs of children and adolescents must be taken into account when making level of care decisions involving their treatment for mental health or substance use disorders.

• The determination of the appropriate level of care for patients with mental health and/or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.

Remember, even though the process is daunting, don’t give up; the right tools, support, and persistence can make a difference.

Several factors contribute to disenrollment, including consolidation and failure of health plans, employer-directed changes in health plans in order to obtain better value, enrollees' search for better drug benefits (1), psychiatric diagnosis (2,3), and overall dissatisfaction with the plan (4).

When a person's health plan is replaced, there may be a sudden disruption to treatment if the enrollee's current behavioral health care provider is not part of the new provider network.

For behavioral health care in particular, disruption to treatment may have dire consequences.

It threatens the therapeutic relationship (5), may result in some anxiety and insecurity on the part of the patient (6), and could even cause serious damage to the therapeutic process.

Persons with mental illness are especially vulnerable.

For example, one study showed that persons with symptoms of depression were less likely to disenroll from a health plan when they were dissatisfied than were enrollees with physical symptoms (2).

A careful literature review found no further research addressing the transition of behavioral health care from one plan to another.

Presented here is a model that was used during the transition of 4,075 active commercial and Medicare enrollees from a large medical managed care organization (MCO) to an academic managed behavioral health care organization (MBHO).

We present a best-practices model to guide the transition of behavioral health enrollees between plans.

Transition goals and guidelines In early 2000, AvMed Health Plan, the largest nonprofit MCO in Florida, awarded a full-risk capitation contract to University of Miami Behavioral Health to manage its South Florida mental health and substance abuse benefits for 186,634 commercial and Medicare covered lives.

AvMed's statewide enrollment was 319,109 lives—covered by commercial insurance, point-of-service plans, Medicare, and Medicaid—of whom 58.5 percent were in South Florida (7).

University of Miami Behavioral Health is a division of the department of psychiatry and behavioral sciences of the University of Miami School of Medicine.

It was established in 1993 as the managed behavioral health care carve-out for the faculty and staff of the University of Miami and their dependents (16,000 lives).

Initially, the provider network comprised university faculty and community clinicians known to the university community.

When planning began for the assumption of AvMed enrollees, the initial enrollee population had expanded to 40,000, and the provider network had increased to 100 licensed professionals.

The ultimate expansion of services would increase enrollment by a factor of almost 5.

AvMed (the MCO) and University of Miami Behavioral Health (the MBHO) hoped to realize specific strategic advantages from the union.

The MCO hoped to gain a high-quality delegate for behavioral health services and the prestige and recognition of the University of Miami in South Florida.

Its primary concern was that the care of its enrollees not be disrupted.

A measure of enrollee satisfaction would be the absence of telephone calls and complaints to AvMed's member services department during the 90-day transition of active enrollees.

The academic MBHO was taking a calculated risk, because an expansion of five times its enrollee population would leave the organization vulnerable if full-risk capitation were not sufficient to cover utilization expenses.

In addition, there would be a cultural shift from a small organization with a generous benefit plan and a provider network composed disproportionately of academic psychiatrists to a community-based network.

Implementation planning began on March 1, 2000, and the transition began on July 1, 2000.

Preparing for the transition of enrollees The challenge facing both health care organizations was to plan the logistics of transferring ongoing treatment by identifying MCO enrollees who were in treatment, notifying their providers, and preparing both enrollees and providers for the change in behavioral health coverage.

The MCO gave the MBHO an electronic list that was used to match active enrollees to providers inside and outside the MBHO network.

The MBHO's network was expanded to include 95 percent of the MCO's providers in the case of geographic overlap between the two networks.

Thus MCO enrollees who were in active behavioral health treatment fell into two groups: those who were being treated by one of 75 providers who were already in the MBHO network, and those who were being treated by an MCO provider who was not in the MBHO network.

The first group would make a smooth transition: providers were mailed a list of affected patients and were informed that after a given date they should request authorizations for continued care from the MBHO instead of from the MCO.

Any benefit limits were transferred to the MBHO.

For the second group, an innovative approach was required so that ongoing treatment would not be disrupted.

Identifying enrollees at risk of treatment disruption Of the MCO's total enrollee population (186,634), 4,075 (2.2 percent) were receiving behavioral health services at the time of the transition—that is, they were active enrollees.

These active enrollees and their providers were notified by mail 30 days before the planned transition date.

A letter was sent to the providers in the MBHO network to inform them of the date on which they should begin to use an authorization process that was familiar to them.

Providers who were not in the network received preemptive authorization for three visits to allow them to continue treatment before the assigned transition date and were invited to join the network.

They received authorization for five visits if they joined.

By the end of October 2000, 97.1 percent of the MCO's active enrollees were being treated by providers in the MBHO network.

Network development and relations In the lexicon of managed care, benefit plans that have been sold to businesses (commercial plans) and defined populations—for example, Medicare and Medicaid—are referred to as product lines.

Within the commercial product line, corporate groups of enrollees are called accounts.

Because these accounts constitute a large proportion of its business, the MCO was understandably anxious to ensure that major accounts would experience minimal disruption to their employees' care.

The MCO provided the MBHO with the name of a contact person for each major account that had an employee assistance program.

Each employee assistance program prepared a list of 20 preferred providers who represented the bulk of its referrals.

Psychiatric Services 52:600-602, 2001Link, Google ScholarSelect Your Interests Customize your JAMA Network experience by selecting one or more topics from the list below.

Keywords: Disability; Provider continuity; Reason for no provider; Usual source of care.

Copyright © 2018 Elsevier Inc.

All rights reserved.

Similar articles Disparities in access to health care among middle-aged and older adults with disabilities.

Miller NA, Kirk A, Kaiser MJ, Glos L.

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2014;26(4):324-46.

doi: 10.1080/08959420.2014.939851. PMID: 25010813 Prevalence and reasons for delaying and foregoing necessary care by the presence and type of disability among working-age adults.

Reichard A, Stransky M, Phillips K, McClain M, Drum C.

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doi: 10.1016/j.dhjo.2016.08.001. Epub 2016 Sep 13.

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Horner-Johnson W, Dobbertin K, Lee JC, Andresen EM; Expert Panel on Disability and Health Disparities.

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PMID: 24962662 Free PMC article.

Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses.

McCleery E, Christensen V, Peterson K, Humphrey L, Helfand M.

2014 Sep.

In: VA Evidence Synthesis Program Evidence Briefs [Internet].

Washington (DC): Department of Veterans Affairs (US); 2011–.

PMID: 27606392 Free Books & Documents.

Review.

Rethinking quality in the context of persons with disability.

Lawthers AG, Pransky GS, Peterson LE, Himmelstein JH.

Int J Qual Health Care.

2003 Aug;15(4):287-99.

doi: 10.1093/intqhc/mzg048. PMID: 12930044 Review.

See all similar articles Unmet Needs for Care and Medications, Cost as a Reason for Unmet Needs, and Unmet Needs as a Big Problem, due to Health-Care Provider (Dis)Continuity Michelle L Stransky 1 2 Affiliations PMID: 30574545 PMCID: PMC6295814 DOI: 10.1177/2374373518755499 Free PMC article Abstract Objective: Provider discontinuity is associated with poorer health-care outcomes compared to continuity in studies using retrospective reports of provider (dis)continuity.

This study examined unmet needs for care and assessed cost as the reason for and the level of the problem resulting from unmet needs by provider (dis)continuity using longitudinal data.

Methods: Pooled data on 10 714 working-age adults (aged 18-64) from the Medical Expenditure Panel Survey (panels 16 [2011-2012] and 17 [2012-2013]) were analyzed.

Provider (dis)continuity was defined by 2 reports of having a health-care provider during the period.

Results: Persons who lost providers were more likely to forego medical care and prescription medications, forego care due to cost, and report that delaying care was a big problem than their peers who experienced continuity.

Persons who gained providers were more likely to delay dental care than those who always had, lost, or never had providers.

Conclusions: Persons who experience discontinuity have poorer access to care than their peers who experience continuity.

Public health initiatives should promote longitudinal relationships between persons and health-care providers.

Keywords: cost as barrier to care; provider continuity; provider discontinuity; unmet needs for care; unmet needs for care problems.

The impact of insurance type and forced discontinuity on the delivery of primary care S A Flocke 1 , K C Stange, S J Zyzanski Affiliations PMID: 9267371 Abstract Background: The effect of managed care on important attributes of primary care is poorly understood.

Of particular concern is the potential for annual bidding on managed care contracts, which may cause forced discontinuity of care.

We examined the effect of insurance type and insurance-mandated disruption in continuity of care on the quality of primary care.

Methods: A cross-sectional study design was used to examine 1839 patient visits to 138 community-based primary care physicians.

The quality of primary care delivery was measured with the Components of Primary Care Instrument, a patient-reported indicator of physician knowledge of the patient, interpersonal communication, coordination of care, continuity of care, and patients' preference to see their regular physician.

Results: No significant differences in any of the five indicators of primary care quality were found between patients with independent provider association/preferred provider organization (IPA/PPO) and fee-for-service insurance.

Patients with IPA/PPO health insurance were four times as likely as patients with fee-for-service insurance to report a forced change in their primary care physician (P < or = .01). Individuals forced to change their physician because of changes in their health care insurance scored significantly lower on all five indicators of primary care quality (P < or = .01). Conclusions: The quality of primary care appears to be less dependent on the payment system than on the maintenance of the patient-physician relationship.

Forced disruption of continuity of care is detrimental to patient receipt of quality primary care, and is a potential negative consequence of annual bidding for managed care contracts.

Comment in Managed care and discontinuity of primary care providers: is there evidence of poorer outcomes? Wall EM.

J Fam Pract.

1997 Aug;45(2):125-6.

PMID: 9267369 No abstract available.

Best Practices: Transition of Enrollees From a Managed Care Organization to an Academic Managed Behavioral Health Carve-Out Andrew L.

Brickman , Ph.D., C.

Eldon Taylor , M.S., Charles J.

LoPiccolo , M.D., Omar Hendrix , M.P.A., and Carl Eisdorfer , Ph.D., M.D. Published Online:1 Nov 2002 Sections View article Tools Share The duration of an individual's enrollment in a managed care plan is highly variable.

Several factors contribute to disenrollment, including consolidation and failure of health plans, employer-directed changes in health plans in order to obtain better value, enrollees' search for better drug benefits (1), psychiatric diagnosis (2,3), and overall dissatisfaction with the plan (4).

When a person's health plan is replaced, there may be a sudden disruption to treatment if the enrollee's current behavioral health care provider is not part of the new provider network.

For behavioral health care in particular, disruption to treatment may have dire consequences.

It threatens the therapeutic relationship (5), may result in some anxiety and insecurity on the part of the patient (6), and could even cause serious damage to the therapeutic process.

Persons with mental illness are especially vulnerable.

For example, one study showed that persons with symptoms of depression were less likely to disenroll from a health plan when they were dissatisfied than were enrollees with physical symptoms (2).

A careful literature review found no further research addressing the transition of behavioral health care from one plan to another.

Presented here is a model that was used during the transition of 4,075 active commercial and Medicare enrollees from a large medical managed care organization (MCO) to an academic managed behavioral health care organization (MBHO).

We present a best-practices model to guide the transition of behavioral health enrollees between plans.

Transition goals and guidelines In early 2000, AvMed Health Plan, the largest nonprofit MCO in Florida, awarded a full-risk capitation contract to University of Miami Behavioral Health to manage its South Florida mental health and substance abuse benefits for 186,634 commercial and Medicare covered lives.

AvMed's statewide enrollment was 319,109 lives—covered by commercial insurance, point-of-service plans, Medicare, and Medicaid—of whom 58.5 percent were in South Florida (7).

University of Miami Behavioral Health is a division of the department of psychiatry and behavioral sciences of the University of Miami School of Medicine.

It was established in 1993 as the managed behavioral health care carve-out for the faculty and staff of the University of Miami and their dependents (16,000 lives).

Initially, the provider network comprised university faculty and community clinicians known to the university community.

When planning began for the assumption of AvMed enrollees, the initial enrollee population had expanded to 40,000, and the provider network had increased to 100 licensed professionals.

The ultimate expansion of services would increase enrollment by a factor of almost 5.

AvMed (the MCO) and University of Miami Behavioral Health (the MBHO) hoped to realize specific strategic advantages from the union.

The MCO hoped to gain a high-quality delegate for behavioral health services and the prestige and recognition of the University of Miami in South Florida.

Its primary concern was that the care of its enrollees not be disrupted.

A measure of enrollee satisfaction would be the absence of telephone calls and complaints to AvMed's member services department during the 90-day transition of active enrollees.

The academic MBHO was taking a calculated risk, because an expansion of five times its enrollee population would leave the organization vulnerable if full-risk capitation were not sufficient to cover utilization expenses.

In addition, there would be a cultural shift from a small organization with a generous benefit plan and a provider network composed disproportionately of academic psychiatrists to a community-based network.

Implementation planning began on March 1, 2000, and the transition began on July 1, 2000.

Preparing for the transition of enrollees The challenge facing both health care organizations was to plan the logistics of transferring ongoing treatment by identifying MCO enrollees who were in treatment, notifying their providers, and preparing both enrollees and providers for the change in behavioral health coverage.

The MCO gave the MBHO an electronic list that was used to match active enrollees to providers inside and outside the MBHO network.

The MBHO's network was expanded to include 95 percent of the MCO's providers in the case of geographic overlap between the two networks.

Thus MCO enrollees who were in active behavioral health treatment fell into two groups: those who were being treated by one of 75 providers who were already in the MBHO network, and those who were being treated by an MCO provider who was not in the MBHO network.

The first group would make a smooth transition: providers were mailed a list of affected patients and were informed that after a given date they should request authorizations for continued care from the MBHO instead of from the MCO.

Any benefit limits were transferred to the MBHO.

For the second group, an innovative approach was required so that ongoing treatment would not be disrupted.

Identifying enrollees at risk of treatment disruption Of the MCO's total enrollee population (186,634), 4,075 (2.2 percent) were receiving behavioral health services at the time of the transition—that is, they were active enrollees.

These active enrollees and their providers were notified by mail 30 days before the planned transition date.

A letter was sent to the providers in the MBHO network to inform them of the date on which they should begin to use an authorization process that was familiar to them.

Providers who were not in the network received preemptive authorization for three visits to allow them to continue treatment before the assigned transition date and were invited to join the network.

They received authorization for five visits if they joined.

By the end of October 2000, 97.1 percent of the MCO's active enrollees were being treated by providers in the MBHO network.

Network development and relations In the lexicon of managed care, benefit plans that have been sold to businesses (commercial plans) and defined populations—for example, Medicare and Medicaid—are referred to as product lines.

Within the commercial product line, corporate groups of enrollees are called accounts.

Because these accounts constitute a large proportion of its business, the MCO was understandably anxious to ensure that major accounts would experience minimal disruption to their employees' care.

The MCO provided the MBHO with the name of a contact person for each major account that had an employee assistance program.

Each employee assistance program prepared a list of 20 preferred providers who represented the bulk of its referrals.

Directors of employee assistance programs were guaranteed that credentialing of their preferred providers would be a top priority and contingent on successful credentialing review and acceptance of the plan's fee schedule by the providers.

Any providers who were not in the MBHO network were extended single-case privileges until they were processed through an expedited credentialing review.

Only two providers declined to join the MBHO network, because they deemed the fee structure to be unacceptable.

These two providers were allowed three transition visits to either terminate care or transfer their clients to a provider in the MBHO network.

At the time of the transition, 75 providers in both networks were treating 4,075 active clients.

By the end of October, 98.8 percent of active enrollees were being treated by providers in the MBHO network.

Outcomes of the transition Multiple satisfaction-related outcomes were clearly defined by both the MCO and the MBHO at the outset of the planning process.

The goal for each of these constituencies was to complete the organizational transfer with minimal disruption to ongoing treatment.

Enrollee complaints and satisfaction The MBHO received one complaint from an enrollee who was told by her provider that he was no longer permitted to treat her because he had not been invited to join the MBHO network.

In fact, that provider had been invited to join but declined because of the new fee structure.

The enrollee was informed and subsequently confronted her provider, terminated care with him, and chose another provider from the network.

There was extensive and intensive communication with transferring patients, including explicit notification of complaint procedures.

As a result, enrollees had few surprises about the process.

The MCO received no complaints from enrollees.

Provider complaints and satisfaction Providers were very satisfied with the transition process and experienced no disruption to their clinical practices.

Neither the MCO nor the MBHO received any complaints from providers.

MCO complaints and satisfaction Beginning four months before the initiation of the transition, group meetings were held routinely to identify organizational strengths, thus creating ownership at all levels of both organizations.

Meetings were arranged with senior administrators of the MCO and the MBHO, marketing representatives, and representatives of major accounts to build trust and credibility.

Having the opportunity to discuss their perceived needs allowed employers to "buy in" to the process and gave them a sense of control.

The result of this collaboration was a shared response to the identification and solution of problems, which in turn resulted in a high level of satisfaction on the part of the MCO as well as a shared sense of accomplishment.

Furthermore, the MCO did not receive any complaints from its client employee assistance program or from its own member services department.

Recommendations It has been suggested that disruption to care due to recent withdrawals of Medicaid managed care plans can be mitigated by overlap in local plans' provider networks and transition policies that affect enrollment (8).

The experience we describe suggests that the same is true in behavioral health care.

The relatively smooth transition of active enrollees should become the benchmark for all managed behavioral health care organizations.

Although spontaneous complaints from all stakeholders—patients, clinicians, employee assistance programs, health maintenance organizations, and so on—are an appropriate outcome measure for plan transitions, it is worth considering a more active approach to solicit such feedback.

We hope that the extremely low rate of spontaneous complaints we received reflects our efforts toward a smooth transition.

However, it is possible that if we had solicited complaints we would have received more of them.

In the spirit of determining best practices, we recomend that future efforts in this area involve contacting and informing all stakeholders—ensuring anonymity when possible—and following up with anonymous satisfaction surveys.

Network integration and preemptive enrollee notification is contingent on the MCO's sharing the claims files of active enrollees with the MBHO.

Unfortunately, such cooperation is unlikely without legislative intervention, because the outgoing MBHO has little or no incentive to assist the MBHO in the absence of an ongoing business relationship.

At a minimum, there should be mandated contractual language and perhaps state statutes that require MCOs and MBHOs to provide active client data to new MBHOs at least 60 days before transition.

ADHD=attention deficit hyperactivity disorder.

Figures References Cited by Details Volume 174 Issue 9 September 01, 2017 Pages 877-885 Metrics Article has an altmetric score of 287 Related Articles: Drug Treatments for ADHD Reduce Risk of Substance Use Disorders Philip Asherson, American Journal of Psychiatry, 2017 Concurrent Use of Stimulants and Second-Generation Antipsychotics Among Children With ADHD Enrolled in Medicaid Pravin Kamble et al., Psychiatric Services, 2014 Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis Samuele Cortese et al., American Journal of Psychiatry, 2015 Are You Exploring These Treatment Options for Facial & Truncal Acne? ReachMD Attention deficit hyperactivity disorder in children Lawrence W.

Brown et al., BMJ Best Practice, 2018 ADHD medication does not increase substance abuse risk Healio Powered by Keywords Alcohol Abuse Attention Deficit Hyperactivity Disorder Epidemiology Psychoactive Substance Use Disorder CNS Stimulants The authors thank Kelsey Wiggs for assistance with table preparation.

History Received 14 June 2016 Revised 17 December 2016 Accepted 27 March 2017 Published online 29 June 2017 Published in print 1 September 2017 TABLE 1.

Summary Statistics for ADHD Patients in a Study of ADHD Medication and Substance-Related Problemsa Variable Male Female N % N % Included patients 1,579,704 – 1,414,183 – Medicated at least 1 month 1,319,349 83.5 1,233,425 87.2 At least one medication status switch 910,084 57.6 811,050 57.4 At least one substance-related event 34,655 2.2 24,196 1.7 Median IQR Median IQR Age in years at start of follow-up 21 15–34 28 19–42 Follow-up months 16 8–33 15 8–31 aPatients with at least one medication status switch had at least 1 month with filled prescription coverage as well as at least 1 month with no prescription coverage.

Observed ages ranged from 13 to 64 years at start of follow-up, and observed follow-up ranged from 1 to 120 months.

ADHD=attention deficit hyperactivity disorder; IQR=interquartile range.

TABLE 2.

Continuity of information about psychotropic medication between mental health providers (MHPs) and primary care providers (PCPs) after a new mental health consultationa Medication and dosage correct in PCP chart Medication but not dosage correct in PCP chart Medication not listed in PCP chart

Data are only for the 54 patients whose providers did not use a mutual-access electronic health record.

bMedication groups: hypnotic-benzodiazepine, alprazolam, buspirone, clonazepam, diazepam, lorazepam, triazolam, zaleplon, and zolpidem; dementia medications, donepezil, rivastigmine, and memantine; antidepressants, amitriptyline, bupropion, citalopram, doxepin, duloxetine, escitalopram, fluoxetine, mirtazapine, nortriptyline, paroxetine, sertraline, trazodone, and venlafaxine; antipsychotic and related, aripiprazole, benztropine, haloperidol, olanzapine, perphenazine, quetiapine, risperidone, thiothixene, and ziprasidone Appealing Treatment and Reimbursement Denials Appeal Strategies The APA recommends the following: 1.

Request and review a copy of the MCO’s appeals procedures and utilization review (UR) criteria before initiating any appeals.

2.

Ask for the case manager’s credentials.

Denials of psychiatrists’ services should be made only by psychiatrists.

3.

Request written notification of the reasons for denial and a description of the information required for approval.

This will ensure that subsequent submissions “fit the bill.” 4.

Request names and addresses of the people who should receive applications for an appeal and find out the MCO’s deadline for appeals.

5.

Meet all UR and appeal deadlines.

If you do not, the merits of your case may not matter.

Certification denials due to “administrative noncompliance” are rarely overturned.

If the case is denied on an administrative basis (i.e., a request for continued certification was not made within the specified time, precertification procedures were not followed, or there were benefit coverage exclusions), you’ll need to explain any extenuating circumstances in your appeal.

6.

If your appeal is denied, appeal again.

Many companies offer three or four levels of appeal.

It is advisable to exhaust all levels of appeal before initiating litigation, should you be forced to proceed that way.

7.

Be concise.

Don’t send more information than necessary and be sure to get permission from your patient to release that information.

8.

Request peer review with a psychiatrist trained in the same subspecialty who has experience in the treatment requested.

9.

In an emergency situation, request an “expedited appeal” over the telephone with the consulting psychiatrist.

Most MCOs have such services.

10.

If applicable, ask the patient to enlist the support of his or her Personnel/ Human Resources Department.

MCOs are often more responsive to their paying clients’ complaints than to complaints from physicians.

11.

In cases that are slow to respond to standard treatments, ask the company to “flex benefits” by working with you to find a cost-effective, alternative treatment approach.

12.

If coverage is denied after appealing, some companies may allow you to request an external review of the case with or without some cost-sharing.

13.

In truly egregious cases, copy your appeal to the state insurance commissioner.

Seeing such a “cc” may elicit a more rapid and favorable response.

14.

Contact any professional association you belong to and any consumer advocacy groups that may be helpful.

A complaint lodged by several parties will be stronger.

Letter of Appeal The following are some suggestions for inclusion in a letter of appeal: • Include any literature that supports your case, including references to the APA’s practice guidelines.

This may help convince the reviewer that the proposed treatment will result in the desired outcome.

• Be candid about the patient’s condition.

Describe any changes in diagnosis, comorbidities, progression, or regression of the patient’s condition; special treatments such as suicide restraints and seclusion; neurological testing and other medical tests; medications; and any self-injury or assaultive behavior.

• Clearly relate the level of care requested to the patient’s condition.

Information should be based on objective reasoning, not just opinion.

• Describe the next step of treatment, providing goals and an approximate time frame for the completion of treatment.

This will promote the idea that you have an action-oriented approach.

• If applicable, recommend alternative treatments for the patient.

• Present evidence of similar cases where the care was approved by the same plan.

• Appeal with a collaborative spirit.

If you need further assistance, call the APA Practice Management HelpLine at (800) 343-4671.

Independent Review Organizations (IROs) Most states have enacted independent review laws that require disagreements over what constitutes a health plan coverage to be decided by a review done by a medical expert or panel of medical experts who have no affiliation with the health plan.

Laws vary from state to state as to whether the review decisions are binding, but they are in most states.

Currently, approximately 50 percent of the disputes taken to independent review result in the reversal of a coverage denial.

An independent, external review, however, can only be accessed after the internal appeals process established by individual MCOs has been completely exhausted.

Although independent reviews have been around for years, there is still a lack of public awareness about the process, and patients generally do not take advantage of the reviews despite claims denial letters that inform them about their availability.

In 2005 the Kaiser Family Foundation published a guide to handling health plan disputes that provides specific information about how to access the independent review organizations in each state that has mandated the independent review process.

There are four versions for each state: one comprehensive bill and then three smaller bills that are each of the components of the comprehensive bill (addressing insurer reporting requirements, addressing commissioner implementation requirements, or addressing MAT coverage provisions).

This allows each state to address the needs within that state, such as pursuing an incremental strategy or the comprehensive model legislation.

different versions for each state below.

Top Comprehensive State Model Parity Legislation for Each State This is the comprehensive version of the state model parity legislation, which includes provisions for insurer reporting requirements, commissioner implementation requirements, and addressing MAT coverage provisions.

Find your state's comprehensive model parity legislation op Model Parity Legislation Addressing Insurer Reporting Requirements This version of the model parity legislation is the section that only addresses insurer reporting requirements.

Find your state's model legislation addressing insurer reporting requirements  Top Model Parity Legislation Addressing Commissioner Implementation Requirements This version of the model parity legislation is the section that addresses commissioner implementation requirements only.

Top Model Parity Legislation Addressing MAT Coverage Provisions This version of the model parity legislation is the section that only addresses MAT coverage provisions.

state's model legislation addressing MAT coverage provisions Louisiana APA's Department of Government Relations Team For more information on how your state can get involved in advancing mental health parity, please contact APA Director of Government Relations Erin Berry Philp at ephilp@psych.org

[Date] [Name and mailing address of payer] To Whom It May Concern: I have been seeing [patient name] since [provide date care began] to treat his/her [provide diagnoses, and any problems this may cause in patient’s life if applicable.

For example: Anxiety that has limited her ability to fulfill her duties at work].

[Provide a chronology of the patient’s treatment and explain why you need to either continue or initiate the denied care.

If the company is denying the frequency of care, the chronology will provide an example of how patient decompensated when care was provided with less frequency.

If the denial is for a medication, provide a history of prescribing and explain why you have come to the decision that it’s necessary to either continue or initiate treatment with the denied drug.

Explain any of the patient’s stated concerns/preferences that influenced your decision.

Be sure to provide examples of what might occur if care continues to be denied and how this would be detrimental to the patient’s health.

Always be as specific as you can.] I have attached articles that support provision of this care to [patient name].

[if you can find literature to support the care that is being denied, this can be a very valuable asset.

The APA’s Practice Guidelines can be a good source for support since most insurers say they use them in developing their treatment guidelines.] Sincerely, [Name and contact information] A.

Key Acronyms The following abbreviations are used in this Guide, and are defined in the glossary or within the text: ACA—The Patient Protection and Affordable Care Act (see also PPACA) AHP—Association Health Plan CMS—U.S. Centers for Medicare and Medicaid Services COC—Certificate of Coverage DOL—U.S. Department of Labor EAP—Employee Assistance Program EHBs—Essential Health Benefits EOB—Explanation of Benefits EOC—Evidence of Coverage EPO—Exclusive Provider Organization ERISA—Employee Retirement Income Security Act of 1974 FDA—U.S. Food and Drug Administration FEHB Program—Federal Employees Health Benefits Program FFS—Fee-for-Service FR—Financial Requirement HDHP—High Deductible Health Plans HHS—U.S. Department of Health and Human Services HIPAA—Health Insurance Portability and Accountability Act HMO—Health Maintenance Organization HSA—Health Savings Account IOP—Intensive Outpatient Program IRO—Independent Review Organization MBHO—Managed Behavioral Health Organization MEWA—Multiple Employer Welfare Arrangement Plans MH/SUD—Mental Health and Substance Use Disorders MHPAEA—The Mental Health Parity and Addiction Equity Act of 2008, also known as the Federal Parity Law NQTL—Non-Quantitative Treatment Limitation PCP—Primary Care Provider PHP—Partial Hospitalization Program PPACA—The Patient Protection and Affordable Care Act (see also ACA) POS—Point of Service PPO—Preferred Provider Organization QTL—Quantitative Treatment Limitation SBC—Summary Benefits and Coverage SPD—Summary Plan Description TPA —Third Party Administrator UCR—Usual, Customary and Reasonable UM—Utilization Management Call to Action: Ten Steps A lthough many success stories exist where a patient or ordering provider’s appeal was handled in a timely and efficient manner by a health plan, those cases are the exception and not the norm.

The good news is that the building blocks to achieve true parity implementation are now in place, but more remains to be done.

The following ten steps will advance mental health parity by improving the appeals process for all: 1.

Increase Awareness of the Appeal Process.

The appeals process is enormously complex.

Many individuals do not know they have the right to file an appeal upon receiving an adverse benefit determination.

Health plans and regulators should work together to ensure that all enrollees are aware of their rights through targeted public education campaigns.

Regulators should also reinforce health plans’ parity disclosure requirements and make clear that in both internal and external appeals, a parity violation is grounds for reversal of a coverage denial.

2.

Promote More Due Process and Transparency.

When an adverse benefit determination or denial takes place, more transparency must be provided surrounding how the decision was made and documented.

At a minimum, health plans must disclose the clinical and/or coverage criteria used in the decision and clearly explain the specific steps required to file an appeal.

Regulators should also enforce requirements that denial letters include a detailed explanation of why the patient does not meet the plan’s clinical criteria, a description of the evidence reviewed by the plan, and address evidence submitted by the patient or their provider.

Otherwise, consumers cannot avail themselves of their appeal rights.

Filing An Appeal Based On a Parity Violation The Kennedy Forum • 3.

Allow Attending Providers and other Advocates to File Appeals.

In some instances, ordering or attending providers are not allowed to file an appeal on behalf of their patients.

This is counterintuitive and inefficient as the provider is often in the best position to understand the denial decision and then explain why the service or treatment is still recommended or why the care was already delivered.

Providers also have a “leg-up” as they are familiar with the medical jargon used in the denial letter or throughout the appeals process.

4.

Simplify the Appeals Process.

Many patients and ordering providers complain that too many bureaucratic hurdles and inconsistent requirements exist within the appeals process.

These obstacles have a chilling effect that discourages patients or their representatives from filing an appeal.

Originally, the appeals process made clear that utilization management (UM) appeals handled medical necessity or clinical denials, and grievance procedure appeals handled administrative denials.

Today, model laws from the National Association of Insurance Commissions (NAIC) and many jurisdictions have issued regulations that have eroded this formerly clear bifurcation.

We recommend that one integrated and streamlined appeals process apply no matter the basis of the initial denial.

5.

Standardize the Appeal System Across Market Segments and State Lines.

A national and consistent standard must be implemented to make the appeals process effective.

At present, many different appeal pathways exist.

These pathways vary based on how the health plan is regulated, the type of coverage provided, the type of plan sponsor, the jurisdiction, the type of denial (e.g., based upon a medical necessity or benefit determination), the timing of the denial (e.g., prospective, concurrent and retrospective), the urgency of the care being requested (i.e. standard care versus urgent care), and where the patient is in the appeals process.

Our goal should be to establish one national appeals standard that promotes transparency, fairness and due process to all parties involved.

We can accomplish this unified system through new model legislation, accreditation standards and Requests for Proposal (RFP) requirements.

6.

Upgrade the External Review Appeals Process.

Currently, the patient or their authorized representative must specifically request an external review of their claim.

In most cases, the external review appeal only can be pursued after a patient first successfully completes an appeal through the health plan.

In some instances, the aggrieved party may not even know they have the right to appeal to an external party.

One simple way to address this confusion is to automatically refer the appeal to an independent review organization after the internal appeal is completed.

For example, Medicare beneficiary appeals are automatically referred to the external review level, resulting in more due process.

Filing An Appeal Based On a Parity Violation The Kennedy Forum • In addition, the external review process as currently regulated should be re-examined and potentially upgraded to better protect consumers.

Ideas include: n Reviewer Identification.

In many cases, the patient does not know who made the final ruling during the external review.

Should the identity of the external reviewer be revealed or remain anonymous? Does due process require the person making the judgment to be disclosed like a judge in court? The Kennedy Forum recommends that the identity of the reviewer be routinely disclosed.

n Public Disclosure of Decisions.

In some states, regulators post de-identified external appeal decisions on their websites, a practice that allows consumers and providers to understand the types of issues being sent to external appeals, how external decisions are made, and to identify trends (such as frequent overturns of denials of coverage for specific treatments).

Greater disclosure of external appeal decisions would benefit individual consumers and help frame dialogue with health plans regarding practices that should be reformed.

n Payment.

In most cases, health plans contract with two or more external review organizations to handle the external reviews of their insured population.

Does the external review organization have an incentive to rule in favor of the health plan if the health plan also is paying for the cost of the external review? Should the patient’s health plan pay for the external review? Or should it be funded by a government agency or through some sort of fund supported by all health plans in a particular jurisdiction? The Kennedy Forum recommends that some sort of payment system be set up through the local jurisdiction rather than through the health plan to avoid any perceived or real conflicts of interest that might bias the external review decision in favor of the health plan.

n Exhausting Internal Review.

Should the patient or their advocate always have to exhaust the health plan internal appeals process before filing an external appeal? Should the patient have the right to skip right to external review? The Kennedy Forum recommends that the patient be permitted to skip the internal UM appeals process and go right to external review if that is their decision.

However, once this decision is made, the patient or their advocate loses the right to use the health plan’s internal appeal system for that particular issue under dispute.

Filing An Appeal Based On a Parity Violation The Kennedy Forum • 7.

File More Appeals.

While working to lower the number of denials issued on claims, stakeholders should simultaneously work to ensure that every questionable denial is subjected to the appeals process so that enrollees receive the care they are entitled to.

Each stakeholder group should do the following to promote the filing of appeals: n Consumer/Provider.

Every patient who has experienced a denial or care restriction of mental health or addiction services should file a complaint at and/or with the applicable government agency.

Filing a complaint will help us develop comprehensive data to better understand the different types of parity denials.

n Industry.

When an appeal is filed, health plan personnel must make a good faith effort to respond in a timely and meaningful manner.

Health plans and medical management organizations must ensure they are complying with existing regulations and the patient’s plan documents on how these appeals should be processed (e.g., timeframes, disclosure requirements).

n Policymakers/Regulators.

Policymakers and public officials must ensure they enforce existing state and federal regulations on how appeals should be filed and processed.

In addition, the current regulatory and accreditation requirements should be updated to create a more efficient and effective appeals process for all parties.

8.

Leverage Technology to Improve the Efficiency of the Appeals Process.

Much like TurboTax has helped tax filers, it is time to leverage technology to promote a more efficient appeals process.

All too often, the appeals process is still paper-based or otherwise very fragmented.

While is one step in the right direction, more can be done.

9.

Update Regulatory Oversight Mechanisms.

It is time to update regulations to capture recent trends in how best to monitor and promote the appeals process.

This could include updating the model laws, regulations and accreditation standards covering utilization management, grievance procedures, external review and mental health parity compliance, both at the federal and state levels.

It also could include promoting value-based and outcome measures.

Regulations need to keep pace with changes in health care delivery, technology capabilities, and communication platforms.

Filing An Appeal Based On a Parity Violation The Kennedy Forum • 10.

Promote Advocacy and Sponsor Education Programs.

States should sponsor and subsidize experts who can help patients understand, file, and process appeals by creating consumer advocate offices, like the Office of the Health Care Advocate in Connecticut or Health Law Advocates in Massachusetts.

Regulators and health insurers can support this effort through customer service lines, supplemental educational programs, broker materials and other resources that are specific to their agency or plan.

These agencies should also actively connect consumers interested in filing an appeal with non-profits capable of supporting individuals throughout the process.

Final Thoughts The appeals process, especially for parity violations, remains a complex and confusing system for most stakeholders.

It is time to rethink and improve on existing appeal systems with an eye towards making the appeals process more efficient, transparent and meaningful.

The impact of doing so will be meaningful for individuals—and their families—who need and deserve care and are entitled to services.

For more information on this topic, contact Garry Carneal, JD, Senior Policy Advisor, The Kennedy Forum, at info@thekennedyforum.org. See also Organize Your Materials What papers do I need? Keep copies of all information related to your claim and the denial.

This includes information your insurance company provides to you, and information you provide to your insurance company, such as: The Explanation of Benefits (EOB) forms or letters showing what payment(s) or service(s) were denied A copy of the request for an internal appeal that you send to your insurance company Any additional information you send to the insurance company (such as a letter or other information from your doctor) A copy of any letter or form you are required to sign, if you choose to have your doctor or anyone else file an appeal for you.

Keep a diary of phone conversations you have with your insurance company or your doctor that relate to your appeal (include the date, time, name, and title of the person you talked to, as well as details about the conversation) Keep your original documents and submit copies to your insurance company.

You will need to send your insurance company the original request for an internal appeal, and your request to have a third party (such as your doctor) file an internal appeal for you.

Make sure you keep copies of all documents for your records.

What kinds of denials can be appealed? You can file an internal appeal if your health plan won’t pay some or all of the cost for health care services you believe should be covered.

The plan might issue a denial because: The benefit is not offered under your health plan Your medical problem began before you joined the health plan You received health services from a health provider or facility that is not in your health plan’s approved network Your health plan determines the requested service or treatment is “not medically necessary” Your health plan determines the requested service or treatment is an “experimental” or “investigative” treatment You are no longer enrolled or eligible to be enrolled in a health plan Your health plan revokes or cancels your coverage, going back to the date you enrolled, because the insurance company claims you gave false or incomplete information when you applied for coverage The Kennedy Forum @kennedyforum Followers you know Followers Following See new Tweets Followers you know American Psychological Association @APA With more than 121,000 members, the American Psychological Association (APA) advances psychological science to promote health, education and human welfare.

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This is an archive of an Obama Administration account maintained by the National Archives and Records Administration (NARA)udge Jackson appointed the Southern Poverty Law Center, National Health Law Program, National Center for Law and Economic Justice, Disability Rights Louisiana, and O'Melveny & Myers, LLP as legal counsel for the class.

The class counsel would like to hear from you if you believe you are a class member or you are impacted by this lawsuit.

If you or a child in your care is a Medicaid recipient under age 21 who has been unable to get Medicaid home or community-based mental health or behavioral health services, please contact the Southern Poverty Law Center at: or 1-800-358-2337.

LA Health Care Services Division Agency Description The LSU Health Care Services Division (LSU HCSD) includes Executive Administration and General Support (Central Office) and six (6) hospitals that have entered into cooperative endeavor agreements (CEA) for public-private partnerships and the Lallie Kemp Regional Medical Center.

The six hospitals that currently have CEAs are the Earl K.

Long Medical Center, University Medical Center, W.O. Moss Regional Medical Center, Washington-St.

Tammany Regional Medical Center, Leonard J.

Chabert Medical Center, and the Medical Center of Louisiana at New Orleans LSU A M LSU Agricultural Center LSU Alexandria LSU Eunice LSU Shreveport LSU Health Sciences Center, New Orleans LSU Health Sciences Center, Shreveport LSU Pennington Biomedical Research Center The Hospital and Central Office of the LSU Health Care Services Division Commitment authorizations for $1,964,876,382 LA Health Care Services Division Lallie Kemp Regional Medical Center HCSD - 8 Executive Budget Supporting Document [FY 2016-2017] DHHS Centers for Medicaid and Medicare Services online survey, certification and reporting database.

Patient satisfaction is measured using The Myers Group, a Centers for Medicare and Medicaid Services (CMS) approved vendor, and is summarized in "overall rating of hospital" and "willingness to recommend hospital." LSU-HCSD has set its performance standards above the state, national and west south regional averages.

LSU-HCSD will follow the CMS rules for reporting; which represents data from a prior quarter being reported due to timing 1: the several campuses as defined below

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Finally, examples of tertiary measures that might be taken by psychiatrists include: • Seeking consultation with experts in behavioral threat assessment and management (see “Consultation” below), • Participating in ongoing risk assessment, especially at critical junctures such as anniversaries and court dates, which may elevate the potential for the stalker to become violent, and • Careful consideration of whether, when, and how to terminate patient care and provision of thoughtful referrals (of the patient) to an appropriate provider (see “Legal and Ethical Issues” below) (Carr et al., 2013).

A special note about boundary-setting: in general, in any therapeutic relationship, setting firm limits and establishing clear boundaries is important (Manca, 2005).

Psychiatrists should examine boundary testing by patients with the possibility that they may progress to stalking.

If a patient violates expected prosocial behaviors and there is a specific concern for stalking behavior, the psychiatrist may consider sending one clear, unambiguous message to the patient to change this behavior (Sandberg et al., 2002; Pinals et al., 2007; McIvor et al., 2008).

However, this approach can require a more nuanced consideration of when and whether to do so.

Caution related to this communication is advised because this may escalate the behavior and increase the risk of retaliation from the stalker in some situations (Sandberg et al., 2002; Pinals et al., 2007).

After a careful weighing of the facts, a decision to “do nothing” may be as impactful and helpful as proactive measures, but each situation requires individualized planning and direction.

Also, victims or identified stalking targets must often make their own decision (preferably with support and guidance) as to what intervention, if any, to take, early in the course of the stalking behavior.

Regardless, if the patient’s behavior persists after reasonable attempts at limit setting, the psychiatrist should try to avoid any direct subsequent engagement with the patient until consultation has been sought (McIvor et al., 2008) (See “Consultation” below).

C) Consultation Seeking consultation, particularly from a multi-disciplinary team, is one of the early steps a psychiatrist should consider in situations involving stalking.

Even for experienced psychiatrists, getting another perspective about their level of concern (e.g., “Am I overreacting or underreacting?”) can be very helpful.

It is also important to acknowledge that each consultation requires a risk assessment and that the facts can evolve, especially as new information about a case becomes available.

Thus, it can be helpful to have a consultant available for the duration of the stalking situation, which may be brief or extend for years.

The specific make-up of the multi-disciplinary team may vary, but often includes law enforcement, hospital security, legal counsel, forensic psychiatric experts, and other hospital or administrative and personal victim supports.

Depending on the setting, a hospital or university may have a threat management team or a forensic psychiatry service (Binder et al., 2017) that can be particularly useful in scenarios that take place in an institutional context.

In a private setting, psychiatrists may consider contacting the nearest university’s forensic psychiatry program, professional organizations like the Association of Threat Assessment Professionals (ATAP), or local law enforcement that has specialized services (e.g., San Diego County District Attorney’s Stalking Unit).

Questions that are commonly asked of consultants beyond violence assessment instruments are:

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Legal and ethical issues, such as concerns regarding breach of confidentiality and abandonment when terminating patient care, often arise when psychiatrists are concerned about being stalked.

Psychiatrists may be in a “double bind,” in which taking appropriate steps may result in a violation of confidentiality or even result in negative consequences for the patient (Carr, Goranson, & Drummon, 2013).

Seeking consultation, and proactively establishing appropriate procedures in healthcare settings for such situations, can help address some of these concerns.

In some settings, for example, psychiatrists may establish a zero-tolerance termination policy (Manca 2005), though legal and risk management guidance for such considerations is strongly advised.

Specific administrative strategies for termination and referrals should also be considered, such as, if indicated, provisions for clear communication to the patient that any contact with the previous psychiatrist (who was stalked) may be criminally prosecuted.

If a termination letter is sent, it should be by certified mail and include referrals to another professional, and might be better to come from the administrative director or clinic rather than the psychiatrist who was stalked (Pinals et al., 2007).

However, there should also be a careful determination of what if any final contact should be generated from the psychiatrist with clear instruction that leaves no room for ambiguity.

If the patient is being referred to an out-of-system provider, then ethical and legal transfer of information is important.

The psychiatrist (who was stalked) should develop a strategy to manage any future contacts - for example, one way to address the issues is that once the patient care has been terminated, it might be prudent for the psychiatrist who was stalked to not respond directly to the ex-patient’s future contacts.

Instead the hospital risk management division should send a clear and polite letter stating that it is hospital policy for the psychiatrist not to respond to the ex-patient, but to address the ex-patient’s needs through the hospital system (e.g., a request for a release of records).

The psychiatrist who will be taking on the treatment of the patient should also carefully consider unique challenges in these situations, such as “stalking by proxy,” which in this case reflects when the patient passes notes or communication to their previous psychiatrist through their new psychiatrist (Carr et al., 2013).

Resources for the Patient A final issue of paramount importance is how to continue providing care in some way for the patient or how to safely refer the patient to the next psychiatrist who may need information as to the reason for the transfer.

There is a fiduciary duty on the part of the physician that needs to be balanced against concerns for their safety.

Depending on the location where the stalking is occurring, several options for patient care include transferring to a different provider in the same location (but possibly in another building) or transferring the patient to another provider altogether.

APA also supports the inclusion of the Behavioral Health Integration codes (99492-99494, G2214, and 99484) in the definition of primary care services for the Shared Savings Program.

Modifications Related to Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs) (section III.O.) We appreciate the two proposed changes included in this section to improve access to care for patients with opioid use disorder by allowing payment for a recently FDA-approved higher dose of naloxone hydrochloride nasal spray product to treat opioid overdose.

We also support allowing the therapy and counseling portions of the weekly bundles, and any additional counseling or therapy provided by opioid treatment programs, to be furnished using audio-only telephone calls rather than via two-way interactive audio/ video communication technology for the duration of the PHE for COVID–19.

This is important given many patients do not have smart phones that allow for two- way communication.

APA appreciates CMS’ intent to align the Provide Patient Electronic Access to Their Health Information measure with the look-back period finalized in the Patient Access and Interoperability final rule.

While the January 1, 2016 date seems reasonable for ECs, the APA recommends that CMS delay enforcement discretion from July 1, 2021, to the end of CY 2021, to account for the ongoing COVID-19 PHE.

Moreover, APA seeks clarification that, during this lookback period, and other proposed future accessibility requirements around changes to the Provide Patient Access PI measure, that ECs can exercise the pertinent Exceptions under the Information Blocking and Interoperability Final Rule.

Specifically, that the Infeasibility, Content and Manner, and Health IT Performance Exceptions may be employed, when applicable, by the EC, when maintaining patient data in near-perpetuity may not be possible for MIPS- eligible clinicians.

Additionally, APA seeks clarification on whether this change to the Provide Patient Access measure will only apply to the reporting years for which the clinician was eligible and did not meet any of the MIPS program exceptions, such as the low-volume threshold.

Clarifying the above points will help to reduce burden among solo and small group psychiatrist ECs who may not participate in MIPS in consecutive years.

14 Reweighting the Promoting Interoperability Performance Category for MIPS Eligible Clinicians in Small Practices APA appreciates CMS’ continued efforts to reduce administrative and financial reporting burden for small practices endeavoring to participate in MIPS.

As noted in this Proposed Rule, many small practices may be eligible for the LVT; or, qualify as small practices (i.e., under 15 ECs), and therefore can apply for an Exception to the Promoting Interoperability category, when there are “overwhelming barriers” to participating.

In response to the questions posed in this Rule, APA is unable to ascertain the specific reason(s) as to why some small practices may fail to apply for the Small Practice Hardship Exception for the Promoting Interoperability performance category, while still participating in MIPS as a whole.

This is possibly because many of our members in solo or small group practices qualify for a total exemption for all of MIPS under the Low Volume Threshold; or, as CMS contemplates in this rule, they may be unaware of the Exception itself, or may believe that they do not meet the requirements of “overwhelming barriers.” Regardless of reason, APA supports CMS’ recommendation to automatically redistribute points from the PI performance category to other performance categories of MIPS for small practices who do not apply for the Exception, but who would have been eligible, in order to avoid receiving a score of zero for the PI category.

(ii) We are proposing to add a new SAFER Guides measure to the Protect Patient Health Information objective...we are proposing that a MIPS eligible clinician must attest to having conducted an annual self assessment using the High Priority Practice Guide, at any point during the calendar year...with one “yes/no” attestation statement accounting for the complete self-assessment using the guide.

Generally, the APA supports the use of the Safety Assurance Factors for EHR Resilience (SAFER) Guides, particularly the High Priority Practices Guide, as a part of the Promoting Interoperability performance category.

Requiring ECs to attest to completing these guides has the potential to help many clinicians enhance and optimize health IT, ensuring that they are “responsible operators of technology tools,” as stated in this proposed rule.

This attestation is reminiscent of the existing Security Risk Assessment measure in its utility to safeguard patient information, and in that it will not be scored for PI.

While we appreciate CMS’ acknowledgement ECs (especially those in solo or small group practice) vary in terms of resources with respect being able to complete the SAFER attestation annually, APA recommends that, for the 2022 RY, CMS conduct an audit of those entities that attest “no,” in order to ascertain why they did not complete a SAFER attestation, to see if additional resources might support them in doing so for future reporting years.

(e) We are also more broadly soliciting public comment to help us better understand the resource costs for services involving the use of innovative technologies, including but not limited to software algorithms and AI.

In addition to this broader prompt, CMS poses a list of questions for consideration regarding the use of innovative technologies within physician practices.

For example, the Rule considers how technologies, 15 such as AI, have affected physician work time and intensity of furnishing services (e.g., possibly reducing the amount of time that a practitioner spends time reviewing and interpreting results of diagnostic testing), or how technologies are changing cost structures, affecting access to services for Medicare beneficiaries, and more.

While APA and psychiatry continues apace in adopting new technologies into clinical workflows—such as adjunctive therapeutic mobile applications, and wearables—it is qualitatively different from how other specialties are using it.

For example, in the Rule, CMS uses examples such as a simulation software analysis of functional data to assess the severity of coronary artery disease and how trabecular bone score software can supplement physician work to predict and detect fracture risk.

These examples might be considered as straightforward use cases of emerging technology where an attempt to codify and quantify their value to Medicare practitioners and beneficiaries seems reasonable.

For psychiatry some analogous use cases, such as various emerging technologies utilizing focused on discrete physiological symptoms (e.g., neuropsychiatry, movement disorders, clinical decision support, work on neurolinguistics in detecting changes in language use patterns in predicting psychopathy or dementia); however, presently, there are too few datapoints and replicated research into how AI or other technologies are or can affect psychiatric work flows, physician time, and other considerations as contemplated in this Rule.

The use of AI in healthcare is still nascent.

With respect to psychiatry, most AI-driven tools are embedded within health IT products more appropriately described as “augmented intelligence” rather than “artificial intelligence.” The scope of this technology tends to encompass features of electronic health records (EHRs), such as electronic clinical decision support (eCDS), and in mHealth, such as apps that rely on patients’ behavioral history to send warnings to the patient about environmental factors that could potentially be triggering for mental health conditions, such as substance use disorders.

While APA is optimistic that the future of AI may improve patient care and lead to better outcomes, we are concerned that there are presently very few standards to which industry is being held in the development of AI in healthcare.

For instance, standards around privacy, security, and confidentiality within health IT is currently in flux.

There are also limited regulatory standards on the development and implementation of AI tools, which further complicates how such tools may be accounted for in terms of quality care and outcomes when integrated into Medicare payment considerations.

ermination Do you have a policy on circumstances that may lead to terminating the relationship with a patient? Does the policy include the state requirements to properly terminate the relationship? The APA is also concerned around background development of AI systems that may not include specific populations within standardization samples in AI beta testing/research studies.

Presently, some algorithms may be based solely on a certain population for various medical conditions (e.g., men or women; various ethnicities; various socioeconomic groups) resulting in algorithms that may not compute the best treatment options or interventions for patients with unique vulnerabilities (e.g., developmental disorders, suicidal ideation, substance use disorders).

Before the technology can be incorporated into Medicare payment models, there needs to be a comprehensive examination (by CMS, the FDA, other entities), of which data are being used to develop any algorithms that influence physician decision-making and patient care.

There needs to be an assurance that AI helps patients regardless of one’s race/ethnicity or other social determinants of health and isn’t introducing or magnifying disparities.

Reporting Requirements

Eligible entities are responsible for meeting specific querying and/or reporting requirements and must register with the NPDB in order to query or report to the NPDB. Entities may qualify as more than one type of eligible entity. In such cases, the entity must comply with all associated querying and reporting responsibilities.

The reporting requirements summarized in Table E-1 are described in greater detail in this chapter. As shown in the table, each of the three major statutes governing NPDB operations has its own reporting requirements. In some instances, actions must be reported based on memorandums of understanding. In certain cases, requirements may exist under more than one statute, or under both a statute and a memorandum of understanding. For example, as discussed in Chapter B: Eligible Entities, the Drug Enforcement Administration's (DEA's) controlled-substance registration actions are reported to the NPDB under Title IV based on a memorandum of understanding; the Department of Health and Human Services (HHS) Office of Inspector General's (OIG's) exclusions from Medicare, Medicaid, and other federal health care programs are reported to the NPDB under Title IV based on an interagency agreement. Both DEA and OIG actions also must be reported to the NPDB under Section 1128E.

Terminology Differences

An action must be reported to the NPDB based on whether it satisfies NPDB reporting requirements and not based on the name affixed to the action by a reporting entity. For example, whether an administrative fine is reportable to the NPDB depends upon whether the fine meets NPDB reporting requirements, not on the name affixed to the fine. A suspension or restriction of clinical privileges is reportable if it meets reporting criteria, whether the suspension or restriction is called summary, immediate, emergency, precautionary, or any other term.

Time Frame for Reporting

Eligible entities must report medical malpractice payments and other required actions to the NPDB within 30 calendar days of the date the action was taken or the payment was made.

The time frame for reporting each type of action described in Table E-1 is summarized in Table E-2.

The NPDB cannot accept reports with a date of payment or a date of action prior to September 1, 1990, with the exception of Medicare and Medicaid exclusions submitted by the OIG.

If an eligible entity discovers documentation of medical malpractice payments, adverse actions, or judgments or convictions that the eligible entity had not reported to the NPDB, the entity must promptly submit the related report(s). All required reports must be filed with the NPDB regardless of whether they are late.

Entities are not excused from reporting simply because they missed a reporting deadline. The Secretary of HHS will conduct an investigation if there is reason to believe an entity substantially failed to report required medical malpractice payments or adverse actions. Entities have the opportunity to correct the noncompliance (see "Sanctions for Failing to Report" to the NPDB in the sections discussing the reporting requirement for each type of action).

Deceased Practitioners

One of the principal objectives of the NPDB is to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without the disclosure or discovery of their previous damaging or incompetent performance. Reports concerning deceased practitioners must be submitted to the NPDB because a fraudulent practitioner could assume the identity of a deceased practitioner. When submitting a report on a deceased practitioner, indicate that the practitioner is deceased in the appropriate data field.

Report Retention

Information reported to the NPDB is maintained permanently in the NPDB, unless it is corrected or voided from the NPDB by the reporting entity or by the NPDB as a result of the Dispute Resolution process.

Civil Liability Protection

The immunity provisions in Title IV, Section 1921, and Section 1128E protect individuals, entities, and their authorized agents from being held liable in civil actions for reports made to the NPDB unless they have actual knowledge of falsity of the information contained in the report. These provisions provide the same immunity to HHS in maintaining the NPDB.

Official Language

The NPDB's official language is English. All reports must be submitted in English. Files submitted in any other language or containing non-alphanumeric characters (e.g., tildes, accents, umlauts) are not accepted.

Louisiana Department of Health announces new Medicaid Executive Director

Notice.

(1) Termination of contract by CMS.
(i) CMS notifies the MA organization in writing at least 45 calendar days before the intended date of the termination.
(ii) The MA organization notifies its Medicare enrollees of the termination by mail at least 30 calendar days before the effective date of the termination.
(iii) The MA organization notifies the general public of the termination at least 30 calendar days before the effective date of the termination by releasing a press statement to news media serving the affected community or county and posting the press statement prominently on the organization's Web site.
(iv) In the event that CMS issues a termination notice to an MA organization on or before August 1 with an effective date of the following December 31, the MA organization must issue notification to its Medicare enrollees at least 90 days prior to the effective date of the termination.

(2) Immediate termination of contract by CMS.
(i) The procedures specified in paragraph (b)(1) of this section do not apply if -

(A) CMS determines that a delay in termination, resulting from compliance with the procedures provided in this part prior to termination, would pose an imminent and serious risk to the health of the individuals enrolled with the MA organization; or
(B) The MA organization experiences financial difficulties so severe that its ability to make necessary health services available is impaired to the point of posing an imminent and serious risk to the health of its enrollees, or otherwise fails to make services available to the extent that such a risk to health exists; or
(C) The contract is being terminated based on the grounds specified in paragraph (a)(4)(i) of this section.

(ii) CMS notifies the MA organization in writing that its contract will be terminated on a date specified by CMS. If a termination is effective in the middle of a month, CMS has the right to recover the prorated share of the capitation payments made to the MA organization covering the period of the month following the contract termination.
(iii) CMS notifies the MA organization's Medicare enrollees in writing of CMS's decision to terminate the MA organization's contract. This notice occurs no later than 30 days after CMS notifies the plan of its decision to terminate the MA contract. CMS simultaneously informs the Medicare enrollees of alternative options for obtaining Medicare services, including alternative MA organizations in a similar geographic area and original Medicare.
(iv) CMS notifies the general public of the termination no later than 30 days after notifying the plan of CMS's decision to terminate the MA contract. This notice is published in one or more newspapers of general circulation in each community or county located in the MA organization's service area.

42 CFR § 422.510

Scoping language

(1) Has failed substantially to carry out the contract.
(2) Is carrying out the contract in a manner that is inconsistent with the efficient and effective administration of this part.
(3) No longer substantially meets the applicable conditions of this part.
(4) CMS may make a determination under paragraph (a)(1), (2), or (3) of this section if the MA organization has had one or more of the following occur:

(i) Based on creditable evidence, has committed or participated in false, fraudulent or abusive activities affecting the Medicare, Medicaid or other State or Federal health care programs, including submission of false or fraudulent data.

(ii) Substantially failed to comply with the requirements in subpart M of this part relating to grievances and appeals.

(iii) Failed to provide CMS with valid data as required under § 422.310.

(iv) Failed to implement an acceptable quality assessment and performance improvement program as required under subpart D of this part.

(v) Substantially failed to comply with the prompt payment requirements in § 422.520.

(vi) Substantially failed to comply with the service access requirements in § 422.112 or § 422.114.

(vii) Failed to comply with the requirements of § 422.208 regarding physician incentive plans.

(viii) Substantially fails to comply with the requirements in subpart V of this part.

(ix) Failed to comply with the regulatory requirements contained in this part or part 423 of this chapter or both.

(x) Failed to meet CMS performance requirements in carrying out the regulatory requirements contained in this part or part 423 of this chapter or both.

(xi) Achieves a Part C summary plan rating of less than 3 stars for 3 consecutive contract years. Plan ratings issued by CMS before September 1, 2012 are not included in the calculation of the 3-year period.

(xii) Has failed to report MLR data in a timely and accurate manner in accordance with § 422.2460 or that any MLR data required by this subpart is found to be materially incorrect or fraudulent.

(xiii) Fails to meet the preclusion list requirements in accordance with § 422.222 and 422.224.

(xiv) The MA organization has committed any of the acts in § 422.752(a) that support the imposition of intermediate sanctions or civil money penalties under subpart O of this part.

(xv) Following the issuance of a notice to the MA organization no later than August 1, CMS must terminate, effective December 31 of the same year, an individual MA plan if that plan does not have a sufficient number of enrollees to establish that it is a viable independent plan option.

The Mental Health Parity and Addiction Equity Act (MHPAEA) 

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that prevents health care service plans from imposing more restrictive benefit limitations on mental health and substance use disorder (MH/SUD) benefits than on medical/surgical coverage.

Health plans must ensure that financial requirements (such as co-pays and deductibles) and treatment limitations that apply to MH/SUD benefits are no more restrictive than the predominant requirements or limitations applied to medical and surgical benefits.

Louisiana Medicaid will complete a compliance review of all services by October 2, 2017. This initiative will ensure Louisiana Medicaid recipients receiving Medicaid and CHIP services receive equal access to physical and behavioral health care.

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 Legislative History 

• 1996: Mental Health Parity Act of 1996 (MHPA) Required certain commercial group health coverage have parity in aggregate lifetime and dollar limits
• 2008: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) Added substance use disorder services and required parity in treatment/financial limitations
• 2013: Final mental health parity rules for commercial plans
• 2016: Final mental health parity rules for Medicaid and CHIP managed care organizations (MCOs)

Classifications

• Louisiana will place each Medicaid service in the following four classifications required in parity analysis:
  • Inpatient
  • Outpatient
  • Emergency Care
  • Prescription Drugs

Treatment Limitations to be Analyzed

• Quantitative Treatment Limitations: Limits on benefits based on the frequency of treatment; examples include:
  • Number of visits
  • Days of coverage
  • Days in a waiting period, or
  • Other similar limits on the scope or duration of treatment
• Non-Quantitative Treatment Limitations: No “hard limits” but limit the ability of a person to receive a certain service or level of services; examples include:  
  • Prior Authorization Processes
  • Concurrent Review
  • “Fail First” Policies

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Image may be NSFW. Clik here to view.
Image may be NSFW. Clik here to view.	Image may be NSFW. Clik here to view.