Texas Mental Health

Condition and

Substance Use

Disorder Parity

Strategic Plan

As Required by

H. B. 10, 85th Legislature,

Regular Session, 2017

Texas Mental Health Condition

and Substance Use Disorder

Parity Workgroup

Month, YYYY

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Contents

Contents ................................................................................................ 1

1. Disclaimer ......................................................................................... 2

2. Executive Summary ........................................................................... 4 Message from the Workgroup.................................................................. 5

3. Legislative Charge ............................................................................. 6

Strategic Planning Process and Methodology ............................................ 6

4. Vision, Mission and Values for the Strategic Plan .............................. 7

Vision .................................................................................................. 7 Mission ................................................................................................. 7 Guiding Principles .................................................................................. 7

Workgroup Roles ................................................................................... 8 Workgroup Meetings .............................................................................. 8

5. The Foundations of Parity: History and Landscape .......................... 10 The Parity Landscape .......................................................................... 11

The Department of Labor ................................................................. 11

The Texas Department of Insurance .................................................. 12 Medicaid and CHIP ......................................................................... 15

The Complaint Process ......................................................................... 15 HHSC Office of the Ombudsman Complaint process ............................. 15 Texas Department of Insurance ........................................................ 21

6. Parity Goals, Objectives and Strategies .......................................... 27 Subcommittee 1: Compliance, Enforcement and Oversight ....................... 27

Subcommittee 2: Complaints, Concerns and Investigations ..................... 28 Subcommittee 3: Education and Awareness ........................................... 30

7. Parity Improvement Recommendations .......................................... 33

8. Glossary of Terms ............................................................................ 34

9. Resources ........................................................................................ 35

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1. Disclaimer

This report was not authored by and does not reflect the views and opinions of the

Texas Health and Human Services system, its component agencies, or staff.

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2. Executive Summary

In health care, “parity” describes the equal treatment of mental health

conditions and substance use disorders (MHC/SUDs) by insurance plans, when compared to coverage for physical health care. When a plan has

“parity” it means that health insurance coverage of mental health is equal to coverage for physical health. For example, if an insurer provides unlimited

doctor visits for a condition like diabetes, then the insurer should also provide unlimited doctor’s visits for MHCs like depression or schizophrenia.1

During the 85th Legislative Regular Session lawmakers passed House Bill 10,

to address ongoing challenges with MHC/SUD parity protections. The goal of the legislation is to ensure all Texans have equal access to physical health

care and behavioral health care.

An important piece of the legislation includes bringing stakeholders together

and establishing a workgroup to develop a Texas strategy and common understanding for successful compliance with parity protections. The Mental

Health Conditions and Substance Use Disorder Parity Workgroup (the Workgroup) was established to study and make recommendations to

increase understanding of and compliance with state and federal rules, regulations, and statutes related to parity protections and use these to

develop a strategic plan.

The legislation charges the Workgroup to study and make recommendations on:

1. Increase compliance with MHC/SUD parity rules, regulations, and statutes;

2. Strengthen enforcement and oversight of these laws at state agencies; 3. Improve the complaint processes relating to potential violations of

parity laws for consumers and providers; and

4. Ensure the Texas Health and Human Services Commission (HHSC) and the Texas Department of Insurance (TDI) can accept information

on concerns relating to these laws and investigate potential violations based on de-identified information and individual complaints; and

5. Increase public and provider education on these laws.

1 Center for Public Policy Priorities , (August 28, 2017), “Mental Health Parity in the 2017

Legislative Session.” Center for Public Policy Priorities, retrieved May 23, 2019.

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The Workgroup is required to develop a strategic plan with metrics to serve

as a roadmap to increase compliance with parity laws.

Message from the Workgroup

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3. Legislative Charge

H.B. 10, 85th Legislature, Regular Session, 2017 requires the Workgroup to

submit a progress report each even-numbered year on September 1 to the appropriate legislative committees and state agencies. The progress report

must include findings, recommendations, and information on the development of the strategic plan including:

Increase compliance with the rules, regulations, and statutes

concerning the availability of, and terms and conditions of, benefits for MHC/SUD services;

Strengthen enforcement and oversight of parity laws at state agencies

Improve the complaint processes relating to potential violations of parity laws for consumers and providers

Ensure HHSC and TDI can investigate potential parity violations based on de-identified information and data submitted by providers in

addition to individual complaints; and Increase public and provider education on these laws.

Strategic Planning Process and Methodology

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4. Vision, Mission and Values for the Strategic Plan

The Workgroup focused efforts on developing a mission, vision, and values

to guide the development of the new MHCSUD Strategic Plan.

Vision

To eliminate barriers to care that consumers and providers commonly

encounter as they seek to obtain, access, and utilize mental health and

substance use disorder services.

Mission

To provide a coordinated approach that serves as a roadmap to improve

compliance, complaint resolution, education, and outreach relating to the

laws concerning benefits for mental health conditions and substance use disorders in Texas.

Guiding Principles

Compliance, education, and outreach efforts relating to the laws concerning

benefits for mental health conditions and substance use disorders in Texas must emphasize:

Accountability: All relevant stakeholders will be subject to oversight

regarding their obligations under the laws. Timely access to care: Consumers in need of care deserve access to

the right care at the right time. Equity: Treatment and service determinations must be made fairly and

impartially. Awareness: All relevant stakeholders should have the opportunity to

know and understand the laws.

Efficiency: Relevant systems must be streamlined, coordinated, and cost-effective.

Continuous improvement and evaluation: Efforts to reduce barriers to care and increase compliance, education, and outreach must be

subject to ongoing and routine continuous improvement and evaluation efforts.

User-friendliness: Relevant systems must be simple, understandable, and navigable.

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Transparency: Relevant stakeholders must have a clear window into

processes concerning benefits for mental health conditions and substance use disorders.

Workgroup Roles

In an effort to improve access to MHCSUD services in Texas, H.B. 10

directed HHSC to create the MHCSUD Workgroup which expires on September 1, 2021. The Workgroup is comprised of representatives from the

following:

HHSC Medicaid and the Children’s Health Insurance Program (CHIP); HHSC Office of Mental Health Coordination;

TDI; Medicaid MCO;

Commercial health benefit plan Mental health provider organization;

Physicians;

Hospitals; Children’s mental health providers;

Utilization review agents; Independent review organizations;

Substance use disorder provider or a professional with co-occurring mental health and substance use disorder expertise;

Mental health consumer; Mental health consumer advocate;

Substance use disorder treatment consumer; Substance use disorder treatment consumer advocate;

Family member of a mental health or substance use disorder treatment consumer; and

HHSC Ombudsman for Behavioral Health Access to Care.

Workgroup Meetings

The MHCSUD Parity Workgroup has met regularly since the the legislation became effective. Meetings were held on:

November 27, 2017 February 20, 2018

April 6, 2018 June 12, 2018

July 24, 2018 July 31, 201

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October 9, 2018

February 12, 2019 June 4, 2019

Meetings include stakeholder testimonials on parity issues from the provider,

consumer, and health plan perspective. National parity experts have also presented on best practices, lessons learned, and national parity trends.

HHSC’s Behavioral Health Ombudsman and Medicaid/CHIP Office provide updates at each meeting on progress toward implementation of legislative

directives. TDI provides regular updates related to H.B. 10 implementation.

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5. The Foundations of Parity: History and Landscape

In health care, “parity” describes the equal treatment of mental health

conditions and substance use disorders in insurance plans, when compared to coverage for physical health care. When a plan has “parity” it means that

health insurance coverage of mental health is equal to coverage for physical health. It is important to note that “parity” requires equal coverage, not

necessarily good or comprehensive coverage.

The idea behind mental health parity is simple: insurance companies should treat MHC/SUDcoverage the same way they treat coverage of medical and

surgical (M/S) care. Coverage should be just as extensive and care should be just as accessible, whether there is a need for inpatient care to treat

addiction or cancer.

Before parity laws were enacted, people in need of MHC/SUD care were

often subject to discrimination in health insurance. If health plans included MHC/SUD benefits at all, they were often more expensive for the insured

person and more limited than M/S benefits, and accessing MHC/SUD benefits often required overcoming more significant administrative barriers compared

to M/S services.2

In 2008, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) with the goal of fixing the

disparities in health insurance coverage for MH/SUD services. However, MHPAEA as passed only applied to health plans offered by large employers

(those with 51 or more employees). In 2010, the Affordable Care Act (ACA) expanded mental health parity protections to apply to most private health

insurance plans. In 2016, federal rules extended federal parity protections to Medicaid Managed Care plans and the Children’s Health Insurance Program

(CHIP).

2 Center for Public Policy Priorities , (August 28, 2017), “Mental Health Parity in the 2017

Legislative Session.” Center for Public Policy Priorities, retrieved May 23, 2019.

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The Parity Landscape

The Department of Labor

The Department of Labor (DOL), the Department of Health and Human Services (HHS) and the Treasury issued the rules for implementation of

MHPAEA along with all additional guidance. DOL oversees most employer-sponsored plans. This includes 2.2 million private insurance plans, which

cover 130.8 million individuals. DOL provides education for insurers, providers and regulators and conducts investigations based on complaints

received through their website.

DOL’s Employee Benefits Security Administration (EBSA) gives presentations

at outreach events around the country each year to provide training on the obligations of health plans and individuals’ rights under parity. They hold

webinars, develop consumer-focused publications, and provide compliance assistance tools and checklists designed to improved understanding of parity

requirements. They work with the Substance Abuse and Mental Health Services Administration (SAMHSA) to host several policy academies to

support state regulators with parity enforcement responsibilities. EBSA staff issued a proposed model disclosure request form that an individual or

provider can use to request information to evaluate parity when they have received a denial.

EBSA relies on investigators to review plans for compliance with parity. The

investigations are conducted out of the regional offices. The Texas office is in

Dallas. Investigations are based on leads from the DOL Benefit Advisors and other enforcement agencies, and feedback from consumer groups. Since

October 2010, EBSA has conducted over 1,700 targeted investigations in connection with MHPAEA, and cited more than 300 violations. This includes

191 investigations closed with 44 cited for violations in 2016 and 187 investigations with 92 violations cited in 2017.

DOL parity investigations can take a year or more. The process generally

followed is:

Relevant documents are collected

Interviews and depositions are conducted Initial analysis may be coordinated with attorneys, economists, subject

matter experts, and other partners Coordination with HHS and Treasury is required

Coordination with state insurance department may be involved

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If a violation is determined, voluntary correction is attempted

If the insurer agrees to remedy violation, determination of appropriate redress is determined and implementation is monitored

Plan documents are updated to correct any violations identified

EBSA cannot directly enforce MHPAEA with insurance companies, even when there is evidence of a parity violation. They also cannot assess civil

monetary penalties in egregious cases of noncompliance to deter bad actors. When violations are identified, the plan is asked to make necessary changes

and to re-adjudicate any improperly applied benefit claims. Any penalties are limited to equitable relief. EBSA has no authority to assess penalties. The MH

Parity and SUD Parity Task Force and the President’s Commission on Combating Addiction and the Opioid Crisis have both recommended

Congress allow DOL to assess civil monetary penalties for parity violations.

The Texas Department of Insurance

TDI first adopted rules to implement MHPAEA in 2011.3 Consistent with the federal statute, these rules focus on the financial requirements4 and numerical

treatment limits5 within plans issued to employers with at least 51 employees (large employer health plans). After H.B. 10 passed in 2017, TDI expanded

its parity review to include association, individual, and small employer plans.

Historically, TDI's form review function has been the primary enforcement

mechanism for parity. The Life and Health Lines Office reviews and approves the policy form of each health benefit plan issued to Texas residents. For each

health benefit plan filing, staff evaluate the financial requirements and treatment limitations for compliance with parity and the following related

laws:

Coverage for autism spectrum disorder, consistent with Insurance Code, Section 1355.015 and 28 TAC, Chapter 21, Subchapter JJ, subject to

exclusion by consumer choice plans authorized under Insurance Code,

Chapter 1507; Coverage for serious mental illness, consistent with Insurance Code,

Section 1355.004;

3 28 Texas Administrative Code (TAC), Chapter 21, Subchapter P 4 Financial requirement: A requirement that includes deductibles, copayments, coinsurance, and out-of-

pocket expenses, but excludes an aggregate lifetime limit and an annual limit in accordance with the

definitions and applications of those limits in 28 TAC, Chapter 21, Subchapter P. 5 Treatment limitation: A limitation that includes limits on the frequency of treatment, number of visits,

days of coverage, or other similar limits on the scope or duration of treatment.

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Coverage for inpatient care in a residential treatment center for children

or adolescents; or a crisis stabilization unit, consistent with Insurance Code, Chapter 1355, Subchapter B;

Coverage for care in a psychiatric day treatment facility, and offer of coverage for treatment of mental or emotional illness, consistent with

Insurance Code, Chapter 1355, Subchapter C; and Coverage for chemical dependency, consistent with Insurance Code,

Chapter 1368, subject to exclusion by consumer choice plans authorized under Insurance Code, Chapter 1507.

TDI staff review financial requirements and numerical treatment limits to

ensure that benefits for MHC/SUD are not less generous than medical and surgical benefits. TDI staff looks for disparities but does not perform the

mathematical analysis required under federal rules. That analysis looks at expected M/S claim amounts aggregated by category of coverage. TDI does

not collect this type of information. Instead, staff questions or objects to all

disparities, and requires a change or an explanation confirming compliance. For forms with variable material,6 staff ensures that the company’s

explanation of variability states that any bracketed amounts will be issued in compliance with parity requirements.

After HB 10 passed, TDI expanded form review checklists to review any non-

numerical treatment within health plan contracts, like utilization management requirements and the methodology used to calculate reimbursements for out-

of-network benefits. However, form review and other existing regulatory processes do not allow TDI to evaluate most non-numerical treatment limits

for parity compliance. Instead, TDI staff closely reviews complaints about behavioral health access to care and questions how company processes

adhere to parity requirements. TDI takes enforcement action where appropriate.

TDI’s complaint process produces data that can identify complaint patterns for a company. In addition to a “mental health parity” reason code, the data also

contains relevant keywords, including alcoholism, chemical dependency, and mental illness. TDI treats all complaints with these keywords and codes as

relating to parity and behavioral health access to care. Staff sends complaints needing additional attention to subject-matter experts for review. A complaint

with evidence of an alleged violation of insurance laws may be sent to TDI’s Enforcement Section for further investigation.

6 Rules at 28 TAC, Section 3.4(e), permit forms to be filed with variability, including a range of cost-sharing

amounts. For example, a schedule of benefits may reflect a deductible of [$0 - $10,000].

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TDI is working to incorporate mental health parity into its market conduct and

quality of care examinations examination processes. The NAIC’s Market Conduct Examination Standards (D) Working Group recently adopted

resources for state regulators to use when examining a company for MHPAEA compliance. These resources include parity-related questions and a data

collection tool to address financial requirements and numerical and non-numerical treatment limits. Certain plans are subject to “quality of care”

exams on a regular basis: every three years for health maintenance organizations and every five years for exclusive provider organizations (EPOs).

TDI may examine other insurers through a general or targeted market conduct exam. TDI may perform a targeted exam related to parity based on a pattern

of data that suggests an issuer is not meeting parity requirements.

TDI regulates utilization review agents (URAs) and processes for prior authorization and appeals, which are a key area of interest for parity

compliance. While TDI requires clinical screening criteria to be evidence-based

and compatible with established principles of health care, it does not have the clinical expertise to determine whether URA screening criteria and procedures

are medically appropriate. TDI staff review URA policies and procedures on the front end and look for parity issues, like barriers to behavioral health care

access that do not exist in the M/S policies and procedures. Outside of the one-time HB 10 data collection, TDI does not currently collect data that would

highlight potential parity issues related to screening criteria or processes for prior authorization and appeals that occur in practice. Additional data

reporting may be considered in rulemaking planned to start later in 2019.

TDI’s network adequacy regulation ensures that networks include access to the following categories of behavioral health providers:

psychiatrists; psychologists;

chemical dependency treatment facilities, including residential, partial hospitalization, and intensive outpatient facilities;

crisis stabilization units; and residential treatment, partial hospitalization, and intensive outpatient

facilities for children and adolescents for behavioral health issues.

TDI does not directly assess parity compliance within network adequacy reviews. Preferred provider organization and EPO data reported annually—

related to out-of-network claims and network-related complaints—does not currently distinguish between M/S and MHC/SUD claims and complaints.

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TDI has not yet drafted rules to implement HB 10 and is enforcing the statute

as written. TDI delayed rulemaking to evaluate the data published in TDI’s HB 10 Report in August 2018 and to give the Parity Workgroup a chance to make

recommendations. TDI plans to begin the rulemaking process in mid-2019.

Medicaid and CHIP

Federal law on parity has been evolving since 1996 and was first applied to Medicaid Managed Care Organizations in 1998. On March 29, 2016, the

Centers for Medicare and Medicaid Services (CMS) released final federal rules that extend parity protections to Medicaid MCOs, and CHIP.7

The CMS rule on Medicaid and CHIP parity is designed to align as much as

possible to rules issued to implement MHPAEA. The parity rule was designed to create consistency across the different insurance markets, including

Medicaid and CHIP, employer-sponsored insurance, and the Health Insurance Marketplace. According to the CMS rule, Texas had a due date for

compliance of December 2, 2017.8

Medicaid parity rules require that everyone who receives services through

MCOs or CHIP be provided MHC/SUD benefits that comply with parity. The rules require each state Medicaid agency to perform a “parity analysis” – to

review both M/S health benefits and MHC/SUD benefits offered under insurance plans to determine compliance with the parity protections.. The

regulations also extend parity protections to long term care services for MHC/SUD in the same manner that they are applied to other services.9

The Complaint Process

HHSC Office of the Ombudsman Complaint process

https://hhs.texas.gov/about-hhs/your-rights/office-ombudsman/hhs-ombudsman-

complaint-process

7 Center for Public Policy Priorities, (December, 2017), “Towards Equality for Texans with

Mental Illness: and Substance Use Disorders: A status report on implementing new federal

parity protections,” Center for Public Policy Priorities. Retrieved on May 29, 2017. 8 ibid. 9 Ibid.

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If you are having problems getting behavioral services, including care for mental

health conditions and substance use disorders, the Ombudsman for Behavioral

Health can help. We can answer questions and help you resolve a complaint about

services received at a state hospital or a community mental health center. We can

also help you with concerns about access to behavioral health care through your

health insurance plan, whether it is a private plan or a public plan like Medicaid.

We can help you:

Access behavioral health services

Answer questions about programs and providers

Navigate your health plan's requirements to pay for services

Find a way to solve problems with your services

Understand your rights, including your:

Right to humane treatment

Right to the least restrictive treatment

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Right to participate in the development of your treatment plan

Right to complain

Understand any charges you might need to pay (Excel) at a community

mental health center

Connect to other resources

How to Get Help

There are four ways to contact us:

Call: 800-252-8154, 8 a.m. - 5 p.m., Monday - Friday

If you have a hearing or speech disability, call the toll-free Relay Texas

service at 7-1-1 or 800-735-2989.

Online: Submit your question or complaint online.

Mail: Texas Health and Human Services Commission

Ombudsman for Behavioral Health

P.O. Box 13247

Austin, TX 78711-3247

Fax: 888-780-8099

Publications Explaining Your Rights includes a handbook for consumers

receiving mental health services at state hospitals and through community

mental health centers. There is also a version appropriate for teens.

Accessing Behavioral Health Services Through Your Health Plan

The Texas Insurance Code requires a health plan to provide benefits and coverage

for mental health conditions and substance use disorders under the same terms

and conditions applicable to the plan's medical and surgical benefits and coverage.

This is sometimes referred to as a "parity" law.

Click here to see some common examples of violations of parity laws in

other states.

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Click here to view a resource that explains important concepts related to

parity.

There is also helpful information on the Texas Department of Insurance's page, as

well as on the HHS Medicaid page.

The Ombudsman for Behavioral Health will gather information from you or your

provider about your concerns, and ensure they are sent to the agency that

oversees your health plan. This will vary depending on the kind of insurance you

have. For example, if you have Medicaid, we will work with staff here at Texas HHS

to resolve your concern but if you have insurance through your employer or the

federal health insurance marketplace, we might need to ask the Texas Department

of Insuranceto help.

The Office of the Ombudsman assists when a program's complaint process

cannot or does not satisfactorily resolve the issue.

If you have a problem or complaint, we encourage you to first discuss it

with the person, program or office involved. Many times they can

explain a specific policy or correct the problem immediately. For example,

here is a list of contacts for frequently requested HHS programs:

Community Mental Health Center / Local Mental Health Authority: Contact

the rights protection officer at your local authority.

Eligibility for Medicaid (including long-term services and supports), SNAP

food benefits or TANF cash assistance: Call 2-1-1 or

visit yourtexasbenefits.com

Managed care services (Medicaid or CHIP): Contact your health plan

Medical Transportation Program: Call toll free at 877-633-8747 or visit the

Getting a Ride - Frequently Asked Questions page.

Providers regulated by Texas HHS (including facilities and agencies):

Contact Regulatory Complaint and Incident Intake

State hospitals: contact the rights protection officer at your state hospital

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For more assistance, you can contact the Office of the Ombudsman and we

will help resolve the issue.

When you contact us, here is what you can expect:

We will follow the Texas HHS customer service principles.

We will explain our process and ask if you want us to call or write you with

updates. We will also give you a timeline of how long our work might take.

We arrange translation services to help us communicate with you, if

necessary.

Before asking others to look into your concern, we will research your case

using information from our agency.

If we can’t help you, we will refer you to the proper contact.

Your request will be saved in our records, and you will probably be asked

questions to confirm your identity. We will ask if it is OK before we share

your information with anyone that does not work for Texas HHS.

A more detailed description of our process can be found in our administrative

rules.

If you call us at 877-787-8999, this is what you are going to hear:

You will be given the option of hearing our information in English or Spanish.

You will be advised to first try to contact program staff. You will be advised

your call may be recorded.

Option 1: Out-of-state eligibility workers are asked to call 2-1-1 to complete

their requests.

Option 2: Consumers seeking information about their eligibility for programs

such as Medicaid, SNAP food benefits, and the Temporary Assistance for

Needy Families program.

Option 3: Consumers seeking information about the Autism program, Blind

Children’s Services, Deaf and Hard of Hearing Services, Early Childhood

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Intervention, the Family Violence Program, or the Independent Living

services.

Option 4: Consumers seeking information about Medicaid managed care

services.

Option 5: Consumers seeking information about federal Social Security

benefits.

Option 0: Consumers seeking information about any other HHS program,

including the Healthy Texas Women Program, or the Medical Transportation

Program.

OMBUDSMAN FOR BEHAVIORAL HEALTH COMPLAINT PROCESS

Inquiry/complaint contact is received by the Ombudsman for Behavioral Health

(OBH) via phone, email, fax or letter

Information is entered into HHS Enterprise Administrative Report and Tracking

System (HEART)

Review received complaint information/documentation and determine (in discussion

with the complainant) if case appears to have a potential parity violation

If investigation reveals potential parity violation exist, case is referred to the

appropriate regulatory or oversight agency, including HHSC program staff (for

Medicaid), the Texas Department of Insurance (for private insurance), the U.S.

Department of Labor (for self-funded plans), or the Employee’s Retirement System

(for those covered by the state employee health plan).

The contact is left open until a response is received from the appropriate regulatory

or oversight agency.

If the complaint is regarding services provided by a Local Mental Health Authority

(LMHA), a Local Behavioral Health Authority (LBHA), or a state hospital facility, the

case is referred to the client rights officer of the LMHA/LBHA or the state hospital

facility for investigation and resolution.

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The client rights officer of the LMHA/LBHA or state hospital facility investigates the

complaint and provides a response to OBH regarding the outcome of the complaint

investigation and the resolution communicated to the individual complainant.

Consumer/complainant receives update regarding resolution (and appeal rights if

applicable)

Case is closed in HEART Tracking System

Report data to the HB 10 Work Group (for the parity-related complaints).

Texas Department of Insurance

https://www.tdi.texas.gov/consumer/complfrm.html

Step 1

We encourage people to use our website to ask for help with an insurance

complaint.

Visit tdi.texas.gov to get started.

Step 2

Let us know what issue you’re having with your health insurance to be sure

it’s one that TDI can help with.

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Step 3

If TDI can help, learn more about working with your insurance company first

to resolve your issue. We also tell you about our mediation program. If you

decide that filing a complaint is what you need to do, we’ll give you the

information you need.

Step 4

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Learn about what TDI can do – and can’t do -- to help cwith the complaint

If a patient or provider believes a health plan is violating the law or isn’t

administering the health plan according to the contract, they should file a complaint

with TDI. TDI relies on complaints to learn of violations and identify issues that

warrant enforcement actions. Consumers or providers may file a complaint with TDI

regarding an insurer, HMO, IRO, or URA using TDI's Online Complaint Portal

at www.tdi.texas.gov/consumer/complfrm.html. For more help, call TDI’s Consumer

Help Line at 1-800-252-3439.

https://www.tdi.texas.gov//consumer/complfrm.html

Get help with a health insurance complaint

Step 1: Tell the insurance company you want to appeal its decision.

You can appeal treatment decisions you disagree with. Follow the procedures in the

notice you got telling you the company denied the treatment or service. If your

condition is life-threatening or your health plan stops covering a medication you’re

already taking, you can skip this step.

Step 2: Ask for an external review.

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You can ask for an external review if your insurance company denied a service

because it didn’t consider it medically necessary or because the service is

experimental or investigational. An independent reviewer will decide whether the

insurance company must pay for the service. External reviews are free to you.

How to ask for an external review

If your health plan is through your job with a large employer (more

than 50 employees): Visit the U.S. Department of Labor’s website.

If it’s a Marketplace plan, CHIP plan, stand-alone dental or vision

plan, or a plan though your job with a small employer (fewer than 50

employees): Call 1-888-866-6205 or visit externalappeal.com. You have 60

days from the date your plan sent you the final decision to ask for an

external review.

If it’s a Marketplace plan bought before March 23, 2010: Send a

request form to us. Your insurance company sent you the form when it

denied a service. You can also get it on our website. There’s no deadline, but

it’s a good idea to ask for an external review as soon as possible.

If your plan is through your job with a school district, city or county

government, union, or church: Follow the process in your employee

benefits booklet or ask the benefits coordinator at work.

Step 3: File a complaint with us.

If you’re not happy with the outcome of your appeal, we might be able to help. We

can help with issues involving insurance companies and health plans and people we

regulate. We don’t regulate most health plans. You may need to complain to a

different agency. To learn whether we’re the right agency to complain to, look at

your health plan ID card:

If it says, “TDI” or “DOI” on it, you can complain to us.

If it doesn’t, we probably can’t help you. Talk to your health plan to learn

your options.

Before you complain to us, understand that there are some things we can’t do:

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We can’t decide whether a treatment or service is medically necessary.

We can’t force a company to pay a claim if the company didn’t violate the

law.

We can’t help with complaints about doctors, nurses, pharmacists, hospitals,

and other health care providers. You must complain to the licensing or

enforcement agency that regulates the provider.

File a complaint by using our online complaint system:

You might need to get some documents together. To help you with health

insurance complaints and mediations, we must have the following

documents:

For health insurance complaints, send a copy of the front of your insurance

ID card.

To ask for mediation for a surprise bill from a health provider, send:

A copy of the front of your health insurance ID card.

A copy of your Explanation of Benefits (EOB) form. Your insurance company

sends this form to you after you get health care services.

A copy of the doctor or provider’s bill.

Go to our online complaint system.

After answering some questions, you will be asked if you want to upload

supporting documents. Uploads are limited to 24 pages. If you are not able

to use the online complaint system, you can fill out a paper form:

English: Complaint and Authorization Form (PDF) | Authorization

Form (PDF)

En Español: Formulario de Queja y Autorización (PDF) | Autorización (PDF)

Step 4: Talk to an attorney about your legal options.

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If you need help finding an attorney, visit the State Bar of Texas Lawyer Referral

and Information Service website or call 1-800-252-9690.

Question? Call us at 1-800-252-3439.

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6. Parity Goals, Objectives and Strategies

Subcommittee 1: Compliance, Enforcement and

Oversight

This subcommittee was created to focus on the first two tasks of H.B. 10

· Increase compliance with the rules, regulations, and statutes concerning the availability of, and terms and conditions of, benefits for

MHCSUD; and · Strengthen enforcement and oversight of these laws at state and

federal agencies.

Purpose: To promote compliance and enforcement of MHCSUD rules,

regulations, and statutes.

Goal 1: Understand current MHCSUD and parity-related regulatory and statutory landscape.

· Objective 1.1 Identify current processes for MHCSUD parity

compliance, enforcement, and oversight.

o Strategy 1.1.1 Review existing TDI processes and regulations for parity compliance, enforcement, and oversight.

o Strategy 1.1.2 Review existing HHSC parity compliance evaluation. o Strategy 1.1.3 Review current Centers for Medicare and Medicaid

Services (CMS) and United States Department of Labor (DOL) parity

compliance tools.

· Objective 1.2 Identify best practices for parity compliance, enforcement, and oversight.

o Strategy 1.2.1 Research other states’ regulations, processes, and

oversight tools. o Strategy 1.2.2 Review resources assembled by other stakeholders,

leaders, and consultants.

Goal 2: Recommend opportunities for improvement of MHCSUD parity compliance, enforcement, and oversight.

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· Objective 2.1 Compare current processes and compliance landscape

in Texas to best practices.

o Strategy 2.1.1 Review data produced by H.B. 10 and HHSC’s completed evaluation.

o Strategy 2.1.2 Complete a gap analysis to identify practices and regulations missing from the current Texas framework.

o Strategy 2.1.3 Identify processes and resources needed for effective parity oversight.

· Objective 2.2 Develop recommendations and priorities to improve

processes and procedures for compliance, enforcement, and ongoing oversight.

o Strategy 2.2.1 Maximize state resources by prioritizing quantitative treatment limitations (including financial requirements) and non-quantitative

treatment limitations on which to focus oversight efforts. o Strategy 2.2.2 Recommend oversight tools, including future data

collection and analysis, needed to support ongoing parity oversight. o Strategy 2.2.3 Provide a roadmap for payors, regulators, and

policymakers to implement best practices, including clear parity standards and common terminology for incorporation into such organizations’ standard

operating procedures.

Subcommittee 2: Complaints, Concerns and

Investigations

This subcommittee was created to focus on the third and fourth tasks of H.B. 10:

· Improve the complaint processes relating to potential violations of

these laws for consumers and providers; and · Ensure HHSC and TDI can accept information on concerns relating to

these laws and investigate potential violations based on de-identified information and data submitted to providers in addition to individual

complaints

Purpose: To support consumers, providers, advocates and policymakers by reviewing and improving the process of parity complaints, concerns, and

investigations to increase access to care and remove barriers to service.

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Goal 1: Ensure agency complaint processes for MHCSUD and parity-related

access to care issues are both consumer-centered and capable of supporting providers.

· Objective 1.1 Ensure improvement of the complaint processes by

developing evaluation tools and metrics.

o Strategy 1.1.1 Identify elements of complaints processes that are key to evaluating user satisfaction, including after complaint has been filed and

after complaint has been resolved.

· Objective 1.2 Develop recommendations to mitigate obstacles within current regulatory and oversight agency complaints processes.

o Strategy 1.2.1 Evaluate current agency complaints processes for

simplicity, plain language, readability, and accessibility.

Goal 2: Ensure agency complaints data for MHCSUD and parity-related

access to care issues are consistent, transparent, and actionable.

· Objective 2.1 Develop a complaint reporting template in which agencies can compile data to support parity compliance efforts and inform

consumers, providers, advocates and policymakers.

o Strategy 2.1.1 Identify relevant data components captured within existing agency complaint systems.

Goal 3: Ensure complaints for MHCSUD and parity-related access to care

issues are investigated and resolved timely, effectively, and equitably.

· Objective 3.1 Support agency efforts to identify parity complaints;

evaluate parity compliance; and determine when further investigation is warranted.

o Strategy 3.1.1 Create or identify a toolkit to guide complaints staff

through evaluating potential parity issues.

· Objective 3.2 Provide timely support to consumers seeking access to care, regardless of health plan coverage.

o Strategy 3.2.1 Identify or create resources to enable agencies to connect

consumers with MHCSUD care across the state.

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Subcommittee 3: Education and Awareness

This subcommittee was created to focus on the fifth task of H.B. 10:

· Increase public and provider education on MHCSUD regulations and

laws.

Purpose: To educate all appropriate stakeholders (including, but not limited

to: managed care organizations, commercial insurers, consumers, family members/support systems, advocates, providers, hospitals, public, etc.) on

parity laws in order to increase access to care and ensure awareness of avenues to reconciliation of complaints.

Goal 1: To seek to ensure stakeholders understand federal and state parity

laws and their impact.

· Objective 1.1 Establish a baseline of parity law understanding.

o Strategy 1.1.1 Develop audience-specific surveys of relevant stakeholders to understand their current understanding of parity law.

o Strategy 1.1.2 Review results of surveys to understand gaps in

knowledge of parity law.

· Objective 1.2 Create/provide basic teaching and/or training related to parity laws.

o Strategy 1.2.1 Evaluate resources needed to provide appropriate parity

law education to all relevant stakeholders. o Strategy 1.2.2 Develop audience-specific parity law training modules,

such as webinars, by state agencies to provide fuller understanding of parity law to all relevant stakeholders.

o Strategy 1.2.3 Provide at least one annual update to each relevant stakeholder group on the status of parity law and how it affects them.

o Strategy 1.2.4 Consider options outside of Internet trainings for educating all relevant stakeholders, some of whom may not have readily

available Internet access.

o Strategy 1.2.5 Creation of a quick video explaining parity in layman’s terms.

o Strategy 1.2.6 Use shared branding for TDI and HHSC for use on any and all parity publications.

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Goal 2: Seek to ensure all stakeholders’ needs and perspectives are

considered in the development of strategies that improve parity awareness and education.

· Objective 2.1 Address needs of each stakeholder group through

education at the level according to the intended audience.

o Strategy 2.1.1 Evaluate the language used in awareness and education materials to ensure that it is understandable at all reading levels.

o Strategy 2.1.2 Provide awareness and education materials in a variety of languages to reflect the rich cultural and linguistic diversity of Texas.

o Strategy 2.1.3 Ensure that parity awareness and educational materials can be accessed by stakeholders who keep varying schedules.

o Strategy 2.1.4 Use alternate, every day words to describe parity (i.e. fairness, uniformity, access to behavioral health benefits, etc.)

Goal 3: To ensure that stakeholders’ understand the various federal and state agencies’ roles in ensuring compliance with parity laws.

· Objective 3.1: Expand knowledge of existing regulations.

o Strategy 3.1.1 Identify available resources.

o Strategy 3.1.2 Provide ongoing parity-related continuing education for providers and parity-related educational materials for prospective and

current members and enrollees.

Goal 4: To inform stakeholders about identifying potential parity violations, how to report them, and the resolution process.

· Objective 4.1 Provide culturally sensitive, understandable materials at

an appropriate reading level.

o Strategy 4.1.1 Develop a crosswalk/rubric characterizing or giving

examples of potential parity violations. o Strategy 4.1.2 Have a “track your package” option available where

members can quickly determine what the status is of their complaint.

· Objective 4.2: Identify existing channels within the community to leverage for education.

o Strategy 4.2.1 Educate Maximus, navigators, marketers, etc.

o Strategy 4.2.2 Partner with community/faith based entities.

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o Strategy 4.2.3 Support all relevant stakeholders – including advocacy

groups and trade associations - to develop and distribute education on MHCSUD parity issues.

o Strategy 4.2.3 Work with Disability Rights Texas to support encouragement of self-advocacy.

Goal 5: To ensure evaluation and continuous improvement of education and

awareness efforts.

· Objective 5.1 Develop monitoring program of agencies responsible for education and awareness.

o Strategy 5.1.1 Ask agencies to report on parity education and awareness

activities. o Strategy 5.1.2 Provide regular feedback to agencies on parity education

and awareness activities and recommend improvements.

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7. Parity Improvement Recommendations

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8. Glossary of Terms

Behavioral Health: Mental health and Substance Use Disorder (addiction).

Commercial Health Plan{ For the purposes of this report, the term “commercial health plan” refers to health benefit plans offered by entities

listed in Texas Insurance Code, Chapter 1355, Subchapter F, Section 1355.252.

Medicaid/CHIP Managed Care Organizations:Managed Care is a health care delivery system in which the overall care of a patient is coordinated by

or through a single provider or organization. Managed Care Organizations are contracted by HHSC to provide services for Medicaid and CHIP managed

care clients.

Mental Health Benefit: A benefit relating to an item or service for a mental health condition, as defined under the terms of a health benefit plan and in

accordance with applicable federal and state law.

Non-quantitative Treatment Limitation: A limit on the scope or duration

of treatment that is not expressed numerically. The term includes specific limitations described in Texas Insurance Code, Chapter 1355, Subchapter F,

Section 1355.251(2).

Quantitative Treatment Limitation: A treatment limitation that

determines whether, or to what extent, benefits are provided based on an accumulated amount such as an annual or lifetime limit on days of coverage

or number of visits. The term includes a deductible, copayment, coinsurance, or another out-of-pocket expense or annual or lifetime limit, or another

financial requirement.

Self-funded Health Plan: A self-funded health plan is one in which the

employer pays claims itself. The employer may hire an insurance company,

HMO, or another entity to manage healthcare for clients.

Substance Use Disorder: Substance use disorders can refer to drug and

alcohol dependence.

Substance Use Disorder Benefit: A benefit relating to an item or service

for a substance use disorder, as defined under the terms of a health benefit plan and in accordance with applicable federal and state law.

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9. Resources

1 Medicaid Fact Sheet: Mental Health and Substance Use Disorder Parity

Final Rule for Medicaid and CHIP; (https://www.medicaid.gov/medicaid/benefits/downloads/fact-sheet-cms-

2333-f.pdf) 2 21st Century Cures Act Action Plan for Enhanced Enforcement of Mental

Health Enforcement of Mental Health and Substance Use; https://www.hhs.gov/sites/default/files/parity-action-plan-b.pdf 3 Parity Compliance Toolkit Applying Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children’s Health Insurance

Programs; https://www.medicaid.gov/medicaid/benefits/downloads/bhs/parity-

toolkit.pdf 4 Form to Request Documentation from an Employer-Sponsored Health Plan

or an Insurer Concerning Treatment Limitations;

https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/Model-Form-to-Request-MH-SUD-Treatment-

Limitation-information.pdf

5.American Psychological Association Parity Guide: http://www.apa.org/helpcenter/parity-guide.aspx

Does Your Insurance Cover Mental Health Services? PDF available to download http:// www.apa.org/helpcenter/parity-guide.pdf

6.Department of Labor, Employee Benefits Security Administration (EBSA) Health Plans and Benefits https://www.dol.gov/general/topic/health-

plans/mental Mental Health and Substance Use Disorder Parity Disclosure Request Tool. A

template form to download to request documentation about treatment limitation from an employer-sponsored health plan or an insurer

https://www.dol.gov/sites/default/files/ebsa/laws-and-

regulations/laws/mental-health-parity/mhpaea-disclosure-template-draft-revised.pdf

7.Health Law Advocates Guidance for Advocates: Identifying Parity Violations and Taking Action

www.healthlawadvocates.org 8.HHS Mental Health and Addiction Services Parity Help Web Portal

https://www.hhs.gov/programs/topic-sites/mental-health-parity/mental-health-and-addiction-insurance-help/index.html

9.Hogg Foundation

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Mental Health Parity Fact sheet PDF available to download

http://hogg.utexas.edu/project/ mental-health-parity Directs consumers to Parity Coalition consumer information website Parity Is

Personal https:// parityispersonal.org/ 10.Kennedy Forum

Parity Registry: https://www.parityregistry.org Parity Track: https://www.paritytrack.org/

11.MentalHealth.gov How To Get Mental Health Help - Health Insurance and Mental Health

Services https://www.mentalhealth.gov/get-help/health-insurance

12.NAMI What Is Mental Health Parity: https://www.nami.org/Find-Support/Living-with-a-Mental-Health-Condition/Understanding-Health-

Insurance/What-is-Mental-Health-Parity 13.Parity Implementation Coalition

Simplifying The Appeals Process: Strategies for Winning Disputes With Your

Health Plan Parity Resource Guide for Addiction & Mental Health Consumers, Providers and Advocates https://parityispersonal.org/answers/resources

10.SAMHSA https://www.samhsa.gov/health-financing/implementation-mental-health-

parity-addiction-equity-act https://store.samhsa.gov/shin/content//SMA16-4983/SMA16-4983.pdf

Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits brochure to download https://store.samhsa.gov/product/Know-Your-

Rights-Parity-for-Mental-Health-and-Substance-Use-Disorder-Benefits/SMA16-4971

Consumer Guide To Disclosure Rights: Making The Most Of Your Mental Health and Substance Use Disorder Benefits

https://store.samhsa.gov/product/Consumer-Guide-To-Disclosure-Rights-Making-The-Most-Of-Your-Mental-Health-and-Substance-Use-Disorder-

Benefits/SMA16-4992

14.Shatterproof State Mental Health and Substance Use Disorder Parity Information

https://www.shatterproof.org/advocacy/state-by-state-information/parity 15.Texas Department of Insurance (TDI)

Insurance Coverage and Parity for Mental Health and Substance Use Disorder Services

http://www.texashealthoptions.com/health/mentalhealthcoverage.html 16.Texas Health and Human Services Office of the Ombudsman

Behavioral Health Help https://hhs.texas.gov/about-hhs/your-rights/office-

ombudsman/hhs-ombudsman-behavioral-health-help Directs to Kennedy Forum Parity Track for complaints questions

https://www.paritytrack.org/ know-your-rights/common-violations/

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17. Organizations to Research

Alliance for Health Policy 18. American Academy of Addiction Psychiatry

19. American Association on Health and Disability 20. American Foundation for Suicide Prevention

21. American Group Psychotherapy Association 22. American Psychological Association Practice Organization

23. American Society of Addiction Medicine 24. Association for Ambulatory Behavioral Healthcare

25. Bazelon Center for Mental Health Law 26. California Consortium of Addiction Programs & Professionals

27. Community Catalyst 28. Depression and Bipolar Support Alliance

29. Faces and Voices of Recovery 30. Harm Reduction Coalition

31. Health Law Advocates

32. Kaiser Family Foundation 33. Lakeshore Foundation

34. Legal Action Center 35. Margaret Clark

36. Morgan Foundation 37. Mental Health America (MHA)

38. National Association of Addiction Treatment Providers 39. National Association of County Behavioral Health and Developmental

Disability Directors (NACBHDD) 40. National Association of Psychiatric Health Systems

41. National Association for Rural Mental Health (NARMH) 42. National Association of Insurance Commissioners (NAIC)

43. National Center on Addiction and Substance Abuse 44. National Council for Behavioral Health

45. NCADD-MD

46. Partnership for Drug-FreeKids 47. The Consumers Union

48. The Patient Advocate Foundation 49. The Thomas Scattergood Behavioral Health Foundation

50. Thresholds (Illinois) 51. Treatment Communities of America

52. Treatment Research Institute 53; Depression and Bipolar Support Alliance

54. Hazelden Betty Ford Foundation 55. National Association of Addiction Treatment Providers

56. National Association of Psychiatric Health Systems 57. Young People in Recovery

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58. Departments of Insurance in the five states with the best parity laws:

58. Connecticut: http://www.ct.gov/cid/site/default.asp 59. Maryland: http://www.mdinsurance.state.md.us/sa/jsp/Mia.jsp

60. Minnesota: http://www.state.mn.us/portal/mn/jsp/home.do?agency=Commerce

61. Vermont: http://www.bishca.state.vt.us/insurance/insurance-division 62. Oregon: http://www.cbs.state.or.us/external/ins/index.html

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Strategic Plan Goals - Draft

Subcommittee 1: Compliance, enforcement and oversight

Goal 1 – Ensure 100% of state regulated plans comply with state and federal

parity rules, regulations, and statutes by __________

Goal 2 - State regulations will actively monitor and enforce parity for state

regulated plans.

Subcommittee 2: Complaints, concerns and investigations

Goal 1 – Improve complaint process to be easier to find, access, and

navigate.

Goal 2 – Ensure complaints related to MHC/SUD treatment limitation issues

are investigated and are resolved timely, effectively, and equitably.

Subcommittee 3: Education and Awareness

Goal 1: To ensure stakeholders understand federal and state rights and

responsibilities and their impact on MHCSUD care access.