The parity law (or statute) often referred to as MHPAEA has been in effect since Oct of 2009 and the parity regulations that were released in Feb of 2010 went into effect this July 1 2010.The various Federal agencies are now enforcing the regulations and the law. The Parity Implementation Coalition (PIC) has just released a document of FAQ based on a Patton Boggs Legal Analysis (See Attachment) that gives an analysis of the most common and frequent types of non compliance with parity. This document is easier to follow as compared to prior communications. This is meant to be used by both providers and consumers to ask for reimbursement and then to appeal any denials. In a sense you now have free legal advice to accompany your request for coverage. More about this below. There are several steps that need to be taken if the Neurofeedback community is going to pursue a coordinated approach. While individual clinicians and consumers are already asking for coverage I do not think this approach by itself will be effective. It will be easy for individual insurance plans to rebuff these individual appeals. If there are thousands of requests and appeals accompanied by letters from national organizations then these efforts are likely to be successful. Also the PIC is collecting examples of denials of care and are taking these to the Federal agencies to ask for enforcement so reporting your collective experiences and sending them to the PIC will further increase the chances of success.
MHPAEA does not require group health plans to provide mental health coverage. However, if a plan offers benefits for mental health conditions (as many do), employers and insurers cannot impose stricter limits on this coverage than for medically based health problems. Specifically, the act requires the following:
Deductibles, co-payments, coinsurance, and out-of-pocket expenses must be the same for medical and mental health conditions covered by the plan.
Caps on the frequency or number of visits, limits on days of coverage, or other similar limits on the scope and duration of treatment must be the same for medical and mental health conditions covered by the plan.
If a plan allows members to go outside the network for medical and surgical treatment, they can also now do so for mental health services.
The Act does not specify any particular mental health conditions to be covered, including bulimia. However, whichever mental health conditions a health insurance plan already covers must be covered at parity with medical and surgical coverage. Specifically, the Act prohibits group health plans that offer coverage for mental health and substance-use conditions from imposing treatment limitations and financial requirements on those benefits that are stricter than coverage for medical and surgical benefits. Congress is also requiring a compliance report from employer health plans by January 1, 2012, and every two years to follow.
Prepare a series of sample letters that your patients and also providers can send to insurance plans. You will need several types of letters:
In the case where EEG Neurofeedback is determined to be experimental then the letters you have prepared can use the attached forms here to explain why this denial is illegal. The Legal rationale for appealing a scientific criteria denial is in Section 5 c of the Patton Boggs FAQ. You may want to attach some of these articles about the lack of scientific evidence for common Medical treatments as well -see attachments 3 through 7.
If the reason for denial is no requirement for Scope of Service Parity, then look at the Questions and Answers in Section 1 of the PB FAQ both a and b. The button below contain:
The letters are pretty self-explanatory. You can start using them immediately; particularly the in-network preemptive letter since you do not have to name a client and one must modify the letter for the particular clinical disorder that is the subject matter. Search the National Library of Medicine Database to review and cite the Evidenced Based Medicine for a given clinical disorder and EEG Biofeedback, e.g., search terms: EEG Biofeedback and ADHD. Also one can email and/or call government agencies that are charged with helping you and your patients achieve parity in qEEG and EEG Biofeedback.
There are companies and documents that may help streamline the appeals process. For more information Click Here.
Download the Preemptive Letter for In-Network
Download the Preemptive Letter for Out-of-Network
Download the Sample Telephone Script
Download the Sample Email Script
Download the Spreadsheet for Tracking Health Plans’ Response Letters
Download the Authorization for Release of Information from Health Plans
