APA Urges Explicit Guidance For Exchanges’ Conformity to Parity

APA is urging the government to explicitly detail the obligations of health plans offered in federally facilitated marketplaces, also known as “exchanges,” to comply with the federal Mental Health Parity and Addiction Equity Act (MHPAEA).

Currently 27 states defer most or all of the administration of the exchanges to the federal government.

In a letter dated January 17 to the Center for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services (CMS), APA CEO and Medical Director Saul Levin, M.D., M.P.A., said that insurance plans continue to violate provisions of the MHPAEA and related sections of the Affordable Care Act mandating conformity with the 2008 parity law.

The letter was in response to CMS’s Draft 2017 Letter to Issuers in the Federally Facilitated Marketplaces providing guidance on a wide array of issues including benefit design and provider network adequacy.

Levin urged CMS to explicitly discuss the parity law’s application to exchange plans and strengthen associated reporting and compliance requirements. He also urged the government to implement a robust network “adequacy” standard.

“Network adequacy … is not a reality for far too many patients seeking psychiatric care,” Levin stated. “It is well documented that most health plan directories of psychiatrists purportedly available to treat plan members are woefully inaccurate and create ‘phantom networks.’ For example, a recent Maryland study found that less than 40 percent of the psychiatrists listed in plan directories were actually accepting that plan’s insurance. … While many states have laws defining network adequacy, up until the issuance of your draft letter and related regulation, there has been no national standard.”

The term “phantom networks” refers to networks that may include physicians who are no longer accepting patients, have moved out of a geographic area, or—in some cases—are deceased.

APA’s response letter offers explicit recommendations to the government on how plans should be required to meet standards of adequacy. For instance, Levin urged the government to use a system that looks at claims filed by plans to assess compliance with adequacy standards and to identify phantom networks.

Also, CMS has proposed two possible metrics for quantifying whether plans meet the standards of “reasonable access” to care—a “time and distance” standard or a “provider-to-covered person” ratio.

Levin urged CMS to adopt a time and distance standard to define network adequacy. “Although time and distance standards can have limitations when applied to rural areas, they are better measures of adequacy than a physician-to-beneficiary ratio,” he wrote. “Physicians frequently practice part time in multiple locations, thereby distorting the physician-to-covered-persons ratio. Either standard must account for a physician’s FTE [full time equivalent] status, as well as whether a physician practices in inpatient settings, therefore not being accessible for outpatient care. Examples of established and well-tested geographic-access standards include California’s, which currently apply to all state-licensed plans.”

Further, Levin urged the government to add psychiatry as an explicit specialty area for geographic-access standards and not include it in a broader “mental health” category. Levin also urged CMS to include the full spectrum of inpatient psychiatric facilities in measuring access to psychiatric facilities; these include the following settings: hospital inpatient (psychiatric hospital or psychiatric unit within a hospital), partial hospitalization, residential treatment, partial residential treatment, outpatient, intensive outpatient, and substance use disorder facility services.

Finally, APA urged CMS to adopt standards that account for the time patients may have to wait for an appointment in determining network adequacy.

“Mandating plans to meet time and distance standards does not necessarily go far enough to ensure that patients have timely access to medical care,” Levin wrote. “Patients, particularly those suffering from mental health/substance abuse disorders, need prompt and timely medical care. If plans only have to ensure that providers are within a certain distance and travel time yet patients have to wait extended periods of time before they can get care, they lack adequate access to care.” ■