Resources

The links and tools below may address further questions you may have, but if not please Contact Us.

Health Care Reform Resources

Healthcare.gov

The Department of Health and Human Services has established a page to answer your questions about the Affordable Care Act.

Substance Abuse and Mental Health Services Administration

Information on how the Affordable Care Act affects behavioral health consumers and providers.

The Center for Medicare and Medicaid Services

For more information about Medicaid expansion and Medicare changes.

The Center for Consumer Information and Insurance Oversight

CCIIO is the agency tasked with implementing the Affordable Care Act. You will find more information on the private insurance market reforms on this site.

Kaiser Family Foundation

Kaiser is a non-profit, private operating foundation focusing on the major health care issues facing the U.S. They provide a multitude of studies and policy briefs related to health care reform, including a tool that will help calculate tax subsidies and insurance premiums for those buying through the health benefit exchange.

Maryland Health Benefit Exchange

For more information on Maryland’s state-based health insurance exchange, including stakeholder and Board meetings.

Maryland Health Connection

This site is the face of the new health insurance marketplace. You can compare and purchase individual health plans starting October 2013.

Maryland Women’s Coalition for Health Care Reform

This coalition is very active in health care reform implementation in Maryland. The website has a wealth information about Maryland’s efforts and how you can get involved.

Health Care Access Maryland

HealthCare Access Maryland helps residents enroll in public health care coverage and navigate the complex health care system and was recently selected as Maryland’s Central Region Connector Entity. You can get more information about Medicaid and Exchange Enrollments at this site.

Mental Health America Qualified Health Plan Selection Kit

Created by Mental Health America, this guide details questions to consider when choosing a qualified health plan and outlines possible mental health services one may want to access.

Health Care Reform: Critical Issues for Newly Insured Behavioral Health Consumers

Maryland Parity Project Director, Adrienne Ellis and Professor of Law at University of Maryland Carey Law School has compiled useful  information on patient parity rights, components of the Affordable Care Act and broader reform efforts.

Simplifying the Appeals Process

The Kennedy Forum and Parity Implementation Coalition published this resource guide to increase the general publics’ understanding of the law, how to file a complaint and the steps to appeal denied claims.

Health Care Reform FAQs Guide

The University of Maryland Carey School of Law Drug Policy and Public Health Strategies Clinic has released a collection of “Frequently Asked Questions” with answers for providers and patients who are seeking affordable health care coverage.

Parity Act Resource Guide

Darci Smith and Will Dwyer, student-attorneys of the  University of Maryland Carey School of Law Drug Policy and Public Health Strategies Clinic developed the resource guide for providers and consumers to identify parity issues with insurance companies and entities that administer  Medicaid.

Parity Act Brochure – Equitable Insurance Coverage for Mental Health and Drug Treatment

This brochure outlines a number of questions consumers with a mental health or substance use disorder may have when accessing health care. Following each question, the brochure offers brief answers along with helpful resources.

NDNRC Fact Sheet on Mental Illness

The fact sheet was developed by the National Alliance on Mental Illness (NAMI) to help Navigators better assist consumers with mental health conditions to make an informed-decision when shopping for healthcare coverage.

How Insurance Works

This booklet explains insurance, why it is importance, different insurance programs, and the benefits of health insurance.

How to Use Health Insurance

The Mental Health America outlines the steps one should take to take advantage of their health insurance coverage such as selecting a primary care provider, making appointments and things to bring to your first appointment.

 Redeterminations Fact Sheet for SUD Providers

Download the fact sheet for providers who serve Medicaid beneficiaries.

Medicaid Enrollment Flyer

Download the flyer on how to enroll through our Certified Navigator and useful tips for plan selection.

Selecting an Insurance Plan that Meets Your Behavioral Health Needs

This fact sheet details tips to plan selection and a worksheet to compute plan costs.

FAQs about Affordable Care Act Implementation and Mental Health Parity Implementation

Developed by the Departments of Labor, Health and Human Services and Treasury, this list contains important questions from stakeholders to help people understand the laws and their benefits.

Affordable Care Act Implementation Fact Sheets and FAQs

The Centers for Medicare and Medicaid Services has released numerous fact sheets and FAQs on the implementation of the ACA for stakeholders and consumers.

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Maryland Resources

Maryland Parity Project
For more information about mental health and addictions parity or for help with your insurance coverage of mental health and addiction treatment. http://www.MarylandParity.org

Drug Policy Clinic – University of Maryland School of Law

The Drug Policy Clinic represents individuals who face discrimination based on their history of alcoholism or drug dependence and advocates for the expansion of addiction treatment. The Clinic will assist addiction treatment providers and their patients identify and challenge violations and has developed the Substance Use Provider Parity Resource Guide to help providers understand and enforce the Parity Act.
Download the Substance Use Provider Toolkit.

Contact Ellen Weber, Director of the Drug Policy Clinic, for more information or copies of the Provider Parity Resource Guide. eweber@law.umaryland.edu or 410-706-0590.

Maryland Attorney General Health Education and Advocacy Unit

For information or help filing an appeal with your insurer
www.oag.state.md.us/consumer/HEAU.htm

Maryland Insurance Administration

For more information on filing a claim with Maryland Insurance Administration
http://www.mdinsurance.state.md.us/sa/consumer/file-a-complaint.html

Finding Your Elected Officials
www.mdelect.net

Mental Health Association of Maryland
Download our fact sheet for consumers who need assistance gaining access to care or filing an appeal/complaint with insurer.              Accessing Mental Health Care Fact Sheet

Maryland Community Services Locator
http://www.mdcsl.org/search.html

Medicaid Redeterminations Fact Sheet for Providers
Download the fact sheet for providers who serve Medicaid beneficiaries.  Redeterminations Fact Sheet for SUD Providers

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Federal Resources

National Parity Implementation Coalition
The coalition members have worked for years to pass federal parity legislation and are now monitoring the implementation of the law. Members will answer questions and are collecting data on appeals filed.
Phone: 866-882-6227 www.parityispersonal.org

US Department of Labor

For information on how to file a federal claim
http://www.dol.gov/ebsa/publications/how_to_file_claim.html

US Office of Personnel Management

For more information on Federal Employee Health Benefit Plans
http://www.opm.gov/insure/health/index.asp

US Department of Health and Human Services Centers for Medicare/Medicaid Services

For more information on filing a claim on a fully-insured plan Helpline: 877-267-2323 http://www.cms.gov/SelfFundedNonFedGovPlans/


Federal Register

To see the full text of the Interim Final Regulations
http://edocket.access.gpo.gov/2010/pdf/2010-2167.pdf

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Important Parity Terminology

The following definitions may be useful to you in your navigation through the insurance appeals process.

Behavioral Health

Refers to study, assessment, diagnosis, treatment, and prevention of mental illness and substance use disorders.

Classifications of benefits

For the purposes of the federal parity regulations, plans are divided into 6 different categories of benefits:


Coinsurance

Refers to money that an individual is required to pay for services, after a deductible has been paid. Coinsurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent.

Deductible

A specific dollar amount that your health insurance company may require that you pay out -of-pocket each year before your health insurance plan begins to make payments for claims. Under the parity regulations, plans may not implement a separate deductible for mental health or addiction treatment.

ERISA
(Employee Retirement Income Security Act of 1974)
Establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans. Section 514 preempts all state laws that relate to any employee benefit plan, with certain, enumerated exceptions, including state insurance, but a limitation is placed on the insurance exception, which essentially provides that state insurance law cannot regulate employer self-funded benefit plans. These self-funded plans are often referred to as ERISA plans.

Fully-Insured

In a traditional fully insured health plan, your company pays a premium. The premium rates are fixed for a year, and you pay a monthly premium based on the number of employees enrolled in the plan. The insurance company pays all of the medical claims for the employees therefore holds the risk.

Generic Drug

A prescription drug which is the same as a brand name prescription drug, but which can be produced by other manufacturers after the brand name drug’s patent has expired. Generic drugs are usually less expensive than brand name drugs and are usually the preferred drug of a health plan.

In-network

This refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts. In-network is part of two classifications of benefits under the law, in-network, inpatient and in-network, outpatient.

Inpatient

A term used to describe a person admitted to a hospital for at least 24 hours.

Large Group

Generally, those are business with more than 50 employees. The laws about how coverage can be issued to large groups are different than those for small groups, and the way that premium rates are determined is also different. These health benefit plans are regulated under the parity law and must meet the standard.

Medically Necessary

A basic criterion used by health insurance companies to determine if healthcare services should be covered. A medical service is generally considered to meet the criteria of medical necessity when it is considered appropriate, consistent with general standards of medical care, consistent with a patient’s diagnosis, and is the least expensive option available to provide a desired health outcome.

No More Restrictive

Parity regulations clarify this as, “If a restriction is applied to substantially all the benefits and it is the predominate standard it can be applied no more restrictively to the mental health or addiction benefits than the medical/surgical benefits.” For example, a plan may not make a determination that no mental health inpatient treatment is covered due to lack of medically necessity, but provide panel review to determine the medical necessity of inpatient treatment for medical/surgical benefits.

Non-Quantitative Treatment Limitation

A limitation that cannot be expressed numerically. These are cost containment strategies, often referred to as care management, includes requirements such as prior authorization, step-therapy, prescription drug formulary creation, utilization review, etc.

Out-of-network

Usually refers to health care providers who are considered nonparticipants in an insurance plan. Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual’s insurance company. Out of network applies to two of the classifications of benefits: out-of-network, inpatient and out-of-network, outpatient.

Out-of-Pocket

Insured health care costs for which the consumer is responsible, because of the application of deductibles, coinsurance and co-payments.

Parity

The quality or state of being equal. Mental health parity is the recognition of mental health conditions and addictions as equivalents to physical illnesses.

Predominant

The parity regulations define “predominant” as a requirement or limit applied to 50% of medical/surgical spending in a category. Requirements or limitations for one medical/surgical benefit in a category do not qualify as predominant. For example, a plan may not implement visit limitations for all mental health or addiction inpatient treatment if it only limits orthopedic inpatient treatment on the medical/surgical side.

Prescription Drug Formulary

A list of prescription medications selected for coverage under a health insurance plan. Drugs may be included on a drug formulary based upon their efficacy, safety and cost-effectiveness. Some health insurance plans may require that patients obtain preauthorization before non-formulary (non-preferred) drugs are covered or require that a patient pay a greater share or all of the cost involved in obtaining a non-formulary prescription.

Prior Authorization
(pre-certification, prior authorization)
Most commonly refer to the process by which a patient is pre-approved for coverage of a specific treatment or prescription drug. Health insurance companies may require that patients meet certain criteria before they will extend coverage for some treatments or for certain drugs. In order to pre-approve such a drug or service, the insurance company will generally require that the patient’s provider submit notes and/or lab results documenting the patient’s condition and treatment history.

Quantitative Treatment Limitation

A limitation on treatment that can be expressed in numbers. Examples include: visit limitations, inpatient day limitations, and co-insurance requirements such as co-payments.

Self-Insured

A self-insured plan is when the employer holds the risk of paying for the employee’s health benefit claims. Normally an employer buys insurance and pays a monthly premium for your coverage (you may pay a portion of that monthly fee through payroll deduction). The insurance company pays all of the medical bills for insured employees. If employees have a large amount of medical bills that exceed the total of the monthly premiums collected by the insurance company, the insurer is “at risk” and pays the difference. Some large companies prefer to hold the risk themselves (self-insured) and contract with insurance companies to only administer their insurance plan (i.e. handling enrollment and paying health care providers for services rendered, with the company’s money).

Small Group

The market for health insurance coverage offered to small businesses – those with between 2 and 50 employees in most states. These health benefit plans are not currently regulated under the parity law and are exempt from the standard.

Somatic Care

Affecting the body rather than the mind, often referred to as medical/surgical care.

Standard of Care

A clinically recognized, diagnostic and treatment process that a provider should follow for a certain type of patient, illness, or clinical circumstance. This criterion is often used in deter- mining the medical necessity of a specific treatment.

Substantially All

The parity regulations define “substantially all” as 2/3 of the benefits in one of the six categories of benefits. If 2/3 of the inpatient, in-network medical/surgical benefits are subject to a 20% co-insurance requirement, then inpatient, in-network mental health/addiction benefits cannot be subject to more than 20%.

Usual, Customary and Reasonable (UCR) Charge

The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. It is often employed in determining Medicare payment amounts.

Utilization Review

This term is often used to describe a treatment limitation that plans use to determine if a patient’s use of healthcare services was medically necessary, appropriate, and within the guidelines of standard medical practice. Utilization Management/Review may also be referred to as Medical Review. It can be done prior to treatment, during treatment (concurrent) or post-treatment (retrospective). Retrospective is considered the least restrictive, and prior is considered the most restrictive.

These include overnight or longer stays at a hospital or other facility that is part of your plan network.
These include visits to a mental health/addiction provider that is a member of your insurance plan.
These include overnight or longer stays at a hospital or other facility that isn’t part of your network.
These include visits to a provider who is not a member of your insurance plan.
These include visits and any treatment you receive in the emergency department at a hospital.
This includes coverage for medications prescribed by your provider. Insurance plans often create a preferred drug list, which includes generic medicines as the cheapest and most preferred type of prescription.
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