As an experienced State selected Independent Compliance Administrator (ICA), SAE effectively measures and evaluates health plan compliance with federal Mental Health and Addiction Treatment Parity legislation.
Composed of experienced and knowledgeable behavioral health administrators and clinical experts the SAE ICA team:
- Works collaboratively with each client to identify stages of change required to meet compliance;
- Conducts clinical reviews of medical necessity requirements for specific levels of care;
- Reviews, analyzes and quantifies operational changes in practice, procedures, and policy implementation to measure Parity Compliance; and
- Guides and evaluates the stages of change process at all levels of care to measure the impact of parity compliance and the sustainability of changes required to meet Parity Compliance.
SAE’s Parity compliance strategy encompasses four key integrated monitoring aspects: Benefit Plan Design (Quantitative Limits), Network Compliance, Utilization Management / Utilization Review (Non-Quantitative Limits), and Data Reporting.
Areas of review include (but are not limited to):
Cost-sharing, visit limits, comparability of utilization review processes & necessary reforms, inter-organizational structure and culture to support Parity Compliance, medical necessity/fail-first criteria, adverse determination process and communication, internal and external appeal processes, and network adequacy and comparability.
Substantial data metric sets to identify and evaluate the impact of behavioral health service and system changes include but are not limited to:
- Spend and utilization changes, utilization review rates, medical necessity denial rates, internal appeal/reversal rates and external appeal/reversal rates across all levels of care to measure sustainability of change; and
- High level comparison of utilization review/denial rates and trends for behavioral health services versus those for physical health services.
SAE can help OAGs (Office of the Attorney General) by:
- Providing assistance in gathering both pertinent information and data metric solutions to evaluate the current degree of Parity compliance of a Health plan and its behavioral health vendor – a Discovery phase;
- Functioning as an external Parity compliance administrator, assessing the Health Plan’s movement toward compliance as defined by terms of a settlement; and
- Functioning as an external reviewer of a Health Plan’s internal Parity compliance efforts either voluntarily initiated by the Health Plan or mandated by a settlement derived from litigation.
SAE can help Insurance Commissioners by:
- Guiding them in forming the standards and requirements that Health Plans must demonstrate compliance with;
- Collecting data and analyzing health plan policy and practice, as they relate to the requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA);
- Utilizing a sophisticated data metrics approach to measure compliance against both Quantitative Treatment Limitation (QTL) and Non-Quantitative Treatment Limitation (NQTL) Parity requirements; and
- Determining the information and data needed to begin an overview of a Health Plan’s structure and design.
SAE can help Health Plans by:
- Providing external Parity compliance monitoring of their efforts to meet Parity;
- Helping Health Plans organize their data; and
- Refining their approach and putting a robust structure in place to ensure that Parity compliance is not only met, but also sustained.
- Steven A. Estrine, PhD
- Frank McCorry, PhD
- Loan Mai, PhD
- Alex Hutchinson, MBA
- Brian Baldwin, LCSW
- Maria Messina, PhD
SAE Public Comment on the Department of Labor Website – SAE’s Public Comment on Mental Health and Substance Use Disorder Parity Implementation and the Cures Act Part 38
SAE White Paper – Parity: The Issues, Challenges and Opportunities
SAE Webinar Presentation – Mental Health Parity and Addiction Equity Act (MHPAEA): Measuring and Ensuring Compliance