|
|
Health Plan Options |
|
This email is intended for producers with National, WV, DE, PA, NENY, WNY business or business with our Partner Plans CHANGES TO QUANTITATIVE TREATMENT LIMITATIONS/FINANCIAL RESPONSIBILITY (MHPAEA) Publication of standards developed by a National Association of Insurance Commissioners (NAIC) workgroup surrounding quantitative treatment limitations/financial responsibility (QTL/FR) related to the Mental Health Parity and Addiction Equity Act of 2008 have been closely watched and reviewed by some state insurance examiners.
The standards were developed in support of the same MHPAEA requirements that apply to self-insured plans. And, while we understand that state insurance regulators may not have jurisdiction over your self-insured group health plan, it is our belief that the basis of this approach is well-grounded in federal law and may represent a broader trend in enforcement by both state and federal regulators.
In response, Highmark has redesigned insurance contracts in most of our markets to take into account "dual benefits." More information can be found in the sample client letter found here.
We have requested our self-insured clients choose 1 of 2 options to ensure MHPAEA compliance and notify Highmark by October 15th. Those options are:
1. Opt-Out and no changes will be made to the group health plan(s) benefit designs. Clients are required to confirm they've worked with their legal counsel to ensure their plans are compliant. They may customize their plan to address QTL/FR compliance and would ask clients to accompany the opt-out form with instructions as to how they would like limits to apply on a prospective basis.
2. Take No Action and benefit design changes listed below will be implemented upon contract renewal/anniversary date immediately following December 31, 2023, if the contract anniversary/renewal date matches the plan benefit period, or upon the plan benefit period immediately following December 31, 2023 if the benefit period differs from the contract renewal/anniversary date. We conservatively estimate that these changes will range from 0.35% to 0.7% of total spend.
Benefit Design Changes (Effective January 1, 2024)
- When outpatient mental health/substance abuse benefits apply a copayment, then any copayment applied to urgent care will be waived if the copayment is greater than the second lowest of the following services: (a) primary care physician visit; (b) therapies; (c) specialist visit; and (d) urgent care.
- No copayment will apply to diagnostic services prescribed for the treatment of mental health or substance abuse.
- Visit limits for physical medicine, occupational therapy, and speech therapy will not apply to therapy services for the treatment of a mental health or substance abuse diagnosis.
- When outpatient mental health/substance abuse benefits apply a copayment, then any copayment for physical medicine, occupational therapy, and speech therapy will be waived for the therapy service if the copayment is greater than the second lowest of the following services: (a) primary care physician visit; (b) therapies; (c) specialist visit; and (d) urgent care.
- Inpatient facility and professional charges will be subject to the same cost-sharing. However, satisfaction of the applicable copayment for inpatient facility services will satisfy the copayment cost-share for both the inpatient facility and professional services.
Please reach out to Client Managers with questions.
|
|
|
|
Highmark Inc. is an independent licensee of the Blue Cross Blue Shield Association. Insurance or benefit administration may be provided by or through Highmark Inc. or one of its affiliated Blue companies. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies serve Blue Cross Blue Shield members in the 29 counties of western Pennsylvania, 13 counties in northeast Pennsylvania, the state of West Virginia plus Washington County, Ohio, and the entire state of Delaware. Highmark Blue Cross Blue Shield of Western New York is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. |
|
|
|
|
|
|
|
|
This email and any attachments contain important information about Highmark, including its products, customers and business processes, and may include information which Highmark considers to be confidential and proprietary ("the Highmark Information"). The Highmark Information is intended solely for the use of the individual or entity to which it is addressed, including employees of that entity with a need to access such information. Unauthorized use, disclosure or copying of the Highmark Information, including the posting of such information on a website or social media sites that can be accessed by third parties, is strictly prohibited.
® Highmark is a registered mark of Highmark Inc.
© 2016 Highmark Inc., All Rights Reserved
120 Fifth Avenue Pittsburgh, PA 15222 USA
|
|
|
|
|
|
|