Download The debate over separate but equal deductibles and out

Milliman Behavioral Health Advisor
The debate over separate but equal deductibles and
out-of-pocket limits
My opinion is that the best result will come from providing the right care at the right time
to patients that need it.
The Mental Health Parity and Addictions Equity Act of
2008 requires that “the financial requirements applicable
to such mental health or substance use disorder benefits
are no more restrictive than the predominant financial
requirements applied to substantially all medical and
surgical benefits covered by the plan (or coverage) and
there are no separate cost sharing requirements that are
applicable only with respect to mental health or substance
use disorder benefits”. The interpretation of what this
actually means has produced two distinctly different
opinions:
1.
2.
The medical and behavioral healthcare benefits
share an integrated deductible and out-of-pocket
limit
The medical and behavioral healthcare benefits
can have separate but equal deductibles and outof-pocket limits
Support for Interpretation #1 – Integrated Approach
Supporters of the integrated deductible and out-of-pocket
limit contend that “no separate cost sharing requirements”
means that there is no separate deductible or additional
out-of-pocket requirement for the mental health and
substance use disorder benefits – plain and simple. They
would be subject to the same deductible as all other
medical and surgical benefits. They should not be singled
out as a different healthcare specialty and be treated
differently from cardiology, radiology, oncology, etc.
This integrated approach would require that the
administration of the medical and behavioral benefits must
be integrated – that is, the cost sharing requirements must
be managed together. The claim administration process of
medical and behavioral benefits must work together or
interface, likely with daily feeds of administrative claim
data between the two systems (if they exist separately). If
these systems do not currently interact or “talk to each
other”, it would likely be a significant change to make this
happen, both in the investment of time and dollars.
Support for Interpretation #2 – Separate but Equal
Approach
Supporters of the separate but equal approach believe
that the law is written to allow for plans and health insurers
to have the flexibility to apply either separate or shared
financial requirements to mental health and substance use
disorder benefits.
Some contend that an integrated approach would have a
direct impact on the administrative cost of plans and
create a disadvantage for a significant number of plan
participants by increasing the cost sharing requirements
as a result of the large, extra administrative costs of
changing the systems interface. Heightened cost sharing
may result in limiting access to care and duration of care
for those seeking treatment, which seems to go against
the spirit of the parity act.
Additionally, some contend that if separate but equal was
allowed, it could benefit members with high deductible
plans if the plans could choose to lower the separate
behavioral health deductible rather than having it subject
to the higher integrated deductible (e.g. a $5,000 medical
deductible coupled with a separate $1,000 behavioral
deductible allows for greater utilization of behavioral care
given the lower out of pocket costs compared to a
separate but equal $5,000 behavioral deductible).
What’s the Answer?
We’ll know the correct interpretation(s) hopefully when the
regulations are completed. My opinion is that the best
result will come from providing the right care at the right
time to patients that need it. Design your plan benefits,
provider reimbursements, and systems of care in such a
way that members that need behavioral healthcare can
get it at the right time in an affordable manner – it will likely
lead to a healthier population and lower healthcare costs
over time, and certainly increase productivity of employees
and member satisfaction with their insured benefits.
The Behavioral Health Advisor is a monthly publication by Steve Melek, designed to
bring interesting and informative behavioral health topics to the forefront. Melek is a
leading professional in combining actuarial expertise with behavioral health knowledge.
He consults on effective integration of medical and behavioral healthcare, efficiency in
delivery and successful health outcomes, predictive modeling, and collaborative
research with other disciplines.
July 2009
Stephen P. Melek, F.S.A., MAAA
Principal & Consulting Actuary
Direct: 303 299.9400
[email protected]
milliman.com