November 15, 2020
The following information is an update for NYS Council members regarding ongoing state efforts to improve compliance with federal and state parity laws.
About a year ago, the NYS Office of Mental Health issued a document entitled “Guiding Principles for the Review and Approval of Clinical Review Criteria for Mental Health Services (“Guiding Principles”). The document (sent to all members last November, and attached for your convenience) outlines expectations for MCOs and health plans regarding appropriate utilization review activities for mental health services. Insurers were subsequently instructed to submit their clinical review criteria for mental health services and associated utilization review policies and procedures to the State for review. There is more on this below.
Here’s a link to the OMH Guiding Principles document:https://omh.ny.gov/omhweb/bho/omh_mnc_guiding_principles.pdf
In the Guiding Principles document, OMH noted that the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS)
for adults over 18 years and the Child and Adolescent Level of Care Utilization System (CALOCUS) for children 6-18 years, both published by the American Association for Community Psychiatry (AACP), are clinical review criteria that best adhere to the OMH Guiding Principles. The CALOCUS is also distributed as the Child and Adolescent Service Intensity Instrument (CASII) published by the American Academy of Child and Adolescent Psychiatry (AACAP) and has an accompanying clinical review criteria for services for children age 5 and under called the Early Childhood Service Intensity Instrument (ECSII). Detailed information about the LOCUS & CALOCUS and CASII and ECSII is available online. OMH will approve other clinical review criteria which adhere to the Guiding Principles.
Based on its’ Guiding Principles, OMH recently released a Best Practices Manual: Utilization Review for Adult and Child Services. The Manual outlines best practice approaches to utilization review in a manner that is aligned with the OMH Guiding Principles document as well as state and federal laws related to utilization review and behavioral health parity. All health plans received the Manual, and NYS Council providers / networks should keep it handy when negotiating contracts with MCOs and other payers. Here’s the Manual: https://omh.ny.gov/omhweb/bho/docs/best-practices-manual-utilization-review-adult-and-child-mh-service’s .pdf
Background: About three years ago, DoH and DFS received funds from the federal government to review improve its’ compliance with federal and state parity laws. Some of the funds were used to add additional staff at DFS and DOH, to focus on surveillance and monitoring activities. Other funds were used to hire Milliman – a national consulting firm that conducted a review of state practices designed to ensure NYS compliance with parity laws. Milliman had good things to say about current NYS practices designed to achieve compliance, but it also made recommendations for areas where the state could improve. Results from this ongoing effort include the issuance of numerous citations on health plans, an extensive (almost completed) audit of NQTLs – non-quantitative treatment limits, often employed by health plans, and a recent OMH comprehensive review of the Medical Necessity criteria used by all health plans (MCOs and commercial / private health plans) that provide care to New Yorkers with mental health conditions. The exercise is ongoing but what we can share is that none of the health plans required to share their criteria received the ‘A-OK’ from OMH. In the end, we believe this activity will result in positive changes that will benefit care recipients.
More About NQTLs:
Non-Quantitative Treatment Limits (NQTLs) are processes, strategies, evidentiary standards, or other criteria that limit the scope or duration of benefits for services provided under a plan. Parity laws require that only certain utilization review, prior authorization and plan provisions can be applied to mental health/substance use disorder benefits and only if they are comparable to or less restrictive than those for medical surgical services.
NQTLs can include, but are not limited to:
- Medical management standards limiting or excluding benefits based on medical necessity, medical appropriateness, or based on whether the treatment is experimental or investigative (including standards for concurrent review).
- Formulary design for prescription drugs.
- Network tier design.
- Fail-first policies or step therapy protocols. For example: Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective.
- Exclusions based on failure to complete a course of treatment.
- Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage.
The NYS Council vigorously supports the ongoing efforts of state leaders who are working to achieve increased compliance with federal and state parity laws. It is gratifying to see the states efforts in this regard considering the many years our association spent educating lawmakers and state regulators regarding the myriad issues facing New Yorkers securing care in a timely manner and at the level and for the duration they need it. This is a mission the NYS Council embarked upon 15 years ago when we began meeting with state decision makers on matters related to a range of access to care issues. Together we have secured rate changes, closed loopholes, and passed legislation that codifies timely and full payment practices health plans must abide by. But as we all know, there is still much to do. We need to keep the pressure on, especially given rising overdoes rates, rising incidents of attempted and completed suicides, and the forecast for increased need for our services in the wake of the COVID epidemic.
One final note: It has been interesting to see how OASAS and OMH have approached the challenge of creating change in this area. OASAS and stakeholders across the system made major changes by amending existing insurance laws, and creating new ones, as needed. OMH has pursued a path that focuses more on auditing and surveillance of health plans, requiring them to respond to inquiries, conduct self audits, and citations. Both state agencies have pushed for health plan changes and neither approach is superior. But it has been fascinating to see the state agencies carry out their work and to note the various levers each agency perceives it has to make critical changes.