Last week, comments were due to the New York State Office of Mental Health in regard to definitions of ‘medical necessity’ and the relationship with mental health parity.

One of the most important reforms of the last year was the movement to insure that ‘medical necessity’ in mental health has a universal definition that incorporates peer review and best practices. For too many years, there have been plans that have rejected individual benefits based largely on medical necessity criteria.  A universal definition driven by best practices, a statewide Ombuds program and staff from the Department of Financial Services charged with reviewing plans data will help lead to more individuals and their families getting the mental health benefits that they need. We thank Governor Cuomo and the Office of Mental Health for their leadership on this issue.

MHANYS testimony is listed below

 

We very much appreciate the opportunity to weigh in on the Guidance Principles of Medical Necessity in the criteria for the mental health in parity that was added in this year’s Executive Budget.

Mental Health Association in New York State, Inc. (MHANYS) has had a long history of involvement with behavioral health parity. I served as Co-Chair of the Timothy’s Law campaign and our members were very involved in the passage of the original law. We were also very
involved in helping to make the law permanent and with advocacy around federal parity laws.

Mental Health Parity was landmark legislation that not only put mental health on the same level ‘playing field’ as physical illness but also played a significant role in changing the landscape of how people perceived mental health related issues.

As the legislation has evolved, there have been some significant changes that have occurred. Access to coverage and benefits for some people with mental health related issues have been enhanced by the legislation. For a cadre of individuals, the so-called Quantitative Treatment Limits have been no more restrictive than they have been for medical and surgical benefits. They refer to numerical type benefits, where there has been consistency around coverage for benefits like the 30/20 inpatient and outpatient visits. Other benefits like co-pays and deductibles have been consistent with medical and surgical benefits for many people as well.

However, the real issues around implementation of parity lie in the ‘non-quantitative treatment limits.’ It is in that arena where we have the greatest concern related to denying of benefits.

Those non-quantitative treatment limits are much more difficult to quantify than the numerical quantitative treatment limits. While inpatient/outpatient days are numerical, benefits like ‘medical necessity,’ formularies for prescription medications, prior authorization, provider network, and step therapy have been used as a mechanism to deny benefits.

The major basis for rejection is most specifically around medical necessity. Some insurance plans have used their definition to deny coverage for an individual. Every plan has a varied definition of medical necessity as it relates to mental health. It is in that medical necessity space that so many people are denied much needed and appropriate mental health benefits.

That is why our organization is strongly supportive of OMH’s ability to now provide a true universal definition of medical necessity. The statewide review of ‘medical necessity’ by the clinical staff of OMH will provide peer-reviewed and best practice data that will create a ‘blueprint’ for what insurance plans will need to rely on for medical necessity moving further.

The creation of a best practice ‘medical necessity’ blueprint will provide less ability for a plan to reject an individual based on their definition of medical necessity. All insurer’s plans around ‘medical necessity’ will be reviewed by the New York State Office of Mental Health, the New York State Department of Health, and the New York State Department of Financial Services based on this ‘best practice’ blueprint. In addition, the State’s resources around an ombuds program and Department of Financial Services’ staff dedicated to reviewing this data will benefit all New Yorkers.

On a personal level, the reason we have Timothy’s Law in New York State is because of the perseverance and advocacy of Tom O’Clair who lost his son Timothy to suicide completion. His story reflected what all of us who have a family member with mental health issues realize. Without a robust benefit in place, the discrimination and stigma of mental illness remains in the forefront.

This change around the scope of ‘medical necessity’ will help continue the movement to insure full behavioral health benefits for all New Yorkers who need those benefits, like my loved one and hundreds of thousands of others New Yorkers.

We strongly support this change and thank Governor Cuomo and the New York State Office of Mental Health for their work on this issue.