We had previously commented to our membership that BlueCross BlueShield of Illinois (BCBSIL) decided to rescind its pre-certification requirement for 2010. See the IMHCA Blog June 10, 2010. (http://myimhca.blogspot.com/) Also our past member newsletter.
We heard from many counselors that they had concerns about the changes taking place. Mental Health Professionals in Illinois have been notified that beginning January 1, 2011, they will be required to request preauthorization for all covered behavioral services. They will need to show medical necessity. See Blue Review http://www.bcbsil.com/PDF/bluereview/june_2010.pdf (Page 5)
NASW-IL, the Illinois Psychological Association as well as IMHCA and our members have concerns about this new requirement including:
• A possible violation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 that became law in October of 2008; See more details on Mental Health Parity at : http://cico-il.org/mental_health_parity.html
• Whether the pre-authorization will be burdensome to care and limit access to service, thereby again violating the MHPAEA of 2008; and
• The unclear nature of the required Outpatient Treatment Request (OTR) form to evaluate if the requested services are medically necessary.
If you are a BCBSIL provider, here are some action steps for you to undertake:
• Contact your BCBSIL Network Consultant regarding these concerns;
• Advise your clients to call BCBSIL as well as their employers;
• Let the professional association you belong to (IMHCA) (NAWS-IL) (IPA) know whether or not your clients experience any limited access to care due to the new pre-certification requirement.
The NASW Illinois Chapter has notified the Illinois Department of Insurance and is currently scheduling a meeting with them. We are working with them and the Illinois Pyschological Association and any other allied mental health professional associations on this issue. We will keep our members updated through our member blast emails.
The Department of Veterans Affairs (VA) has issued qualification standards formally recognizing licensed professional counselors as mental health specialists within the Veterans Health Administration.
Citizenship. Be a citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Handbook 5005, part II, chapter 3, section A, paragraph 3g.)
b. Education. Hold a master’s degree in mental health counseling, or a related field, from a program accredited by the Council on Accreditation of Counseling and Related Educational Programs (CACREP). Examples of related mental health counseling fields include, but are not limited to, Addiction Counseling; Community Counseling; Gerontology Counseling; Marital, Couple, and Family Counseling; and Marriage and Family Therapy. A doctoral degree in mental health counseling may not be substituted for the master’s degree in mental health counseling.
c. Licensure. Persons hired or reassigned to LPMHC positions in the GS-101 series in VHA must hold a full, current, and unrestricted license to independently practice mental health counseling, which includes diagnosis and treatment.
Full text http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=507&FType=2
This is better than the previous BCBSIL plan but still calls for a lot of additional effort on the part of the therapist. I am concerned that all mental health services will tack on new pre-certification requirements.
New Pre-authorization Requirements from BCBSIL Effective January 2011
New Preauthorization Requirements
Effective January 2011, BCBSIL will manage behavioral health (behavioral/mental health and substance abuse/chemical dependency) services or all non-HMO members, replacing Magellan Health Services. Behavioral Health care management will be more integrated with our medical care management, allowing our clinical staff to better identify members that would benefit from co-management earlier. This change may result in improved outcomes, enhanced continuity of care, clinical efficiency, and reduced costs over time.
A key change in 2011 will be the requirement for members to preauthorize all outpatient visits for behavioral health services. members will be notified of their responsibility to preauthorize outpatient services. You may preauthorize on behalf of the member by calling the number on the back of the member’s ID card; however preauthorization will ultimately be the responsibility of the member.
Members may receive authorization for up to 10 outpatient visits to any behavioral health provider(s) without the need to submit medical records. Outpatient treatment request (OTR) forms. Please note, however, either the member or the provider will need to preauthorize with BCBSIL prior to the visits, and all outpatient behavioral health services must be deemed medically necessary as outlined in the member’s benefit booklet. Once the preauthorization is received a letter acknowledging the authorization will be mailed to the member and the behavioral health provider. All outpatient behavioral health visits scheduled after he 10th visit will require that you submit an OTR form. The OTR form can be submitted at any point prior to the 11th visit. You can call
BCBSIL with the required information using the number on the back of the member’s ID card.
Will the provider be reimbursed or outpatient services rendered if the member does not call
for reauthorization?
BCBSIL may request an OTR form from the provider to determine medical necessity prior to reimbursement. The member may be responsible for paying claims if services are deemed medically unnecessary.
What are the preauthorization requirements for intensive outpatient programs?
Preauthorization is required prior to the member beginning any of these services. Clinical information will be reviewed to determine medical necessity before authorization.
Transition of Established Patients
BCBSIL will work with all behavioral health professionals to limit the possibility for disruptions in patient care coordination
during this transition. You can use the same phone number on the back of the ember’s ID card for submitting treatment
plans, requesting preauthorization and continuity of care, asking customer service inquiries, and more.
OBAMA ADMINISTRATION ISSUES RULES REQUIRING PARITY IN TREATMENT OF MENTAL, SUBSTANCE USE DISORDERS
Paul Wellstone, Pete Domenici Parity Act Prohibits Discrimination
The Departments of Health and Human Services, Labor and the Treasury today jointly issued new rules providing parity for consumers enrolled in group health plans who need treatment for mental health or substance use disorders.
“The rules we are issuing today will, for the first time, help assure that those diagnosed with these debilitating and sometimes life-threatening disorders will not suffer needless or arbitrary limits on their care,” said Secretary Sebelius. “I applaud the long-standing and bipartisan effort that made these important new protections possible.”
“Today’s rules will bring needed relief to families faced with meeting the cost of obtaining mental health and substance abuse services,” said U.S. Secretary of Labor Hilda L. Solis. “The benefits will give these Americans access to greatly needed medical treatment, which will better allow them to participate fully in society. That’s not just sound policy, it’s the right thing to do.”
“Workers covered by group health plans who need mental health and substance abuse care deserve fair treatment,” said Deputy Treasury Secretary Neal Wolin. “These rules expand on existing protections to ensure that people don't face unnecessary barriers to the treatment they need.”
The new rules prohibit group health insurance plans—typically offered by employers—from restricting access to care by limiting benefits and requiring higher patient costs than those that apply to general medical or surgical benefits. The rules implement the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
MHPAEA greatly expands on an earlier law, the Mental Health Parity Act of 1996 which required parity only in aggregate lifetime and annual dollar limits between the categories of benefits and did not extend to substance use disorder benefits.
The new law requires that any group health plan that includes mental health and substance use disorder benefits along with standard medical and surgical coverage must treat them equally in terms of out-of-pocket costs, benefit limits and practices such as prior authorization and utilization review. These practices must be based on the same level of scientific evidence used by the insurer for medical and surgical benefits. For example, a plan may not apply separate deductibles for treatment related to mental health or substance use disorders and medical or surgical benefits—they must be calculated as one limit. MHPAEA applies to employers with 50 or more workers whose group health plan chooses to offer mental health or substance use disorder benefits. The new rules are effective for plan years beginning on or after July 1, 2010.
The Wellstone-Domenici Act is named for two dominant figures in the quest for equal treatment of benefits. The late Senator Paul Wellstone (D-MN), who was a vocal advocate for parity throughout his Senate career, sponsored the ultimately successful full parity act. He was joined by former Senator Pete Domenici (R-NM) who first introduced legislation to require parity in 1992. Champions of the legislation also included the bipartisan team of Representative Patrick Kennedy (D-RI) and former Representative Jim Ramstad (R-MN).
The issue of parity dates back over 40 years to President John F. Kennedy, and was also supported by President Clinton and the late Senator Edward Kennedy.
The interim final rules released today were developed based on the departments' review of more than 400 public comments on how the parity rule should be written. Comments on the interim final rules are still being solicited. Sections where further comments are being specifically sought include so-called “non quantitative” treatment limits such as those that pertain to the scope and duration of covered benefits, how covered drugs are determined (formularies), and the coverage of step-therapies. Comments are also being specifically requested on the regulation’s section on “scope of benefits” or continuum of care.
Comments on the interim final regulation are due 90 days after the publication date. Comments may be emailed to the federal rulemaking portal at: http://www.regulations.gov/ . Comments directed to HHS should include the file code CMS-4140-IFC. Comments to the Department of Labor should be identified by RIN 1210-AB30. Comments to the Treasury’s Internal Revenue Service should be identified by REG-120692-09. Comments may be sent to any of the three departments and will be shared with the other departments. Please do not submit duplicates.
The rules could take effect as early as July 1, after federal agencies review comments from the public, industry and other interested parties.
The National Council for Community Behavioral Healthcare, a Washington-based advocacy group, said the regulations begin the final chapter in an effort to ensure that Americans with mental illness have equal access to health care.
"Now people in need won't have to go without treatment because of discriminatory insurance policies," president and chief executive Linda Rosenberg said in a statement.
The rules will implement the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
Now, new consumer protections will approach depression the same as diabetes, substance abuse the same as emphysema. Health plans offered by employers with fifty or more workers will have to level the field. No more separate deductible for mental health treatment. And co-payments to see a psychiatrist or social worker can't exceed what's charged to see a family doctor or medical specialist.
The rules carry out changes passed two years ago by congress.
Health plans will no longer be able to set limits on number of visits or hospital days for mental health care, when those limits don't apply to other ailments.
The government estimates the new rules will raise costs for employers only slightly- less than one half of one percent, and the improved coverage will benefit about 140 million Americans. The expanded protections take effect July 1st.
Prevalence of violent acts differs by family income, school attendance, and levels of substance use
A report by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that, in the past year, one quarter (26.7 percent) of adolescent girls participated in a serious fight at school or work, group-against-group fight, or an attack on others with the intent to inflict serious harm.
“These findings are alarming,” said SAMHSA Administrator Pamela S. Hyde, J.D. “We need to do a better job reaching girls at risk and teaching them how to resolve problems without resorting to violence.”
When combined, 2006 to 2008 data from the National Survey on Drug Use and Health (NSDUH) shows that 18.6 percent of adolescent females got into a serious fight at school or work in the past year, 14.1 percent participated in a group-against-group fight, and 5.7 percent attacked others with the intent to seriously hurt them; one quarter (26.7 percent) of adolescent females engaged in at least one of these violent behaviors in the past year. Other key findings from the NSDUH survey include:
The prevalence of these violent acts in the past year decreased as annual family income increased. The violent behaviors were reported by 36.5 percent of adolescent females who lived in families with annual incomes of less than $20,000, 30.5 percent of those in families with annual incomes of $20,000-$49,999, 22.8 percent with annual incomes of $50,000 to $74,999, and 20.7 percent with annual incomes of $75,000 or more.
In the past year, adolescent females who engaged in any of these violent behaviors were more likely than those who did not to have indicated past month binge alcohol use (15.1 vs. 6.9 percent), marijuana use (11.4 vs. 4.1 percent), and use of illicit drugs other than marijuana (9.2 vs. 3.2 percent).
Adolescent females who were not currently enrolled or attending school were more likely than those who were in school to have engaged in one of these violent behaviors in the past year (34.3 vs. 26.7 percent). Among those who attended school in the past year, rates of violent behaviors increased as academic grades decreased.
Despite media attention on high-profile accounts of females’ acts of violence, rates of these violent behaviors among adolescent females remained stable according to the NSDUH report when comparing combined data from 2002-2004 and 2006-2008.
Violent Behaviors among Adolescent Females is based on the responses of 33,091
female youths aged 12 to 17 participating in the 2006, 2007, and 2008 SAMHSA National
We heard from many counselors that they had concerns about the changes taking place. Mental Health Professionals in Illinois have been notified that beginning January 1, 2011, they will be required to request preauthorization for all covered behavioral services. They will need to show medical necessity. See Blue Review http://www.bcbsil.com/PDF/bluereview/june_2010.pdf (Page 5)
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