Final Parity Rule Fulfills Major NABH Requests
Final Parity Rule Fulfills Major NABH Requests
NABH is pleased the U.S. Health and Human Services (HHS), Labor (DOL) and Treasury Departments addressed our major concerns in the final parity rule the three federal agencies released Sept. 9.
The long-awaited regulation implements more stringent compliance protocols and related definitions (noted below) with the goal to implement and enforce the Mental Health Parity and Addiction Equity Act more fully and fairly almost 16 years after it was enacted into law in October 2008.
NABH and our partners will continue to examine the dense, legalistic rule to assess the real-world effects of the new changes and determine our next advocacy steps related to parity. The rule affects group health plans and group or individual health insurance coverage that cover both behavioral and physical health services. Two main provisions in the rule include:
- Requiring health plans to prepare comparative analyses that assess parity compliance of their non-quantitative treatment limitation (NQTL), including specifying the mandatory components of these analyses and the process for publicly sharing these reports; and
- Amending the sunset provision to prevent opting out of compliance with MHPAEA, as required by law, after Dec. 29, 2022, with a June 27, 2023 deadline for certain plans that are subject to collective bargaining.
Key NQTL Provisions
NQTLs include prior authorization requirements and other medical management techniques, standards related to network composition, and methodologies to determine out-of-network reimbursement rates. The rule addresses these NQTL issues by:
- Reinforcing that health plans and issuers cannot use NQTLs that are more restrictive than those predominantly applied to physical health benefits in the same classification.
- Disallowing implementation of new NQTLs that do not meet parity standards.
- Specifying how insurers are to measure and report on their network composition, out-of-network reimbursement rates, and medical management and prior authorization NQTLs.
- Concerning the design of NQTLs, prohibiting discriminatory information, evidence, sources, or standards that systematically disfavor access to behavioral healthcare benefits as compared with physical health benefits.
Fraud, Waste and Abuse
A particularly important win for NABH is the rule’s addition of “fraud, waste, and abuse” standards as a distinct NQTL that is subject to a parity test. Unfortunately, today some health plans exploit providers by using unwarranted fraud, waste, and abuse audits of providers who have no history or evidence of fraud or abuse. For this reason, we strongly urged regulators to implement this new NQTL to provide structure and transparency in these audits.
Generally Accepted Standards of Care (GASC)
Another gain is the rule’s requirement that health plans explain any medical necessity standards that diverge from GASC. While the parity law does not require that medical necessity guidelines align with GASC, this new requirement will bring meaningful transparency and accountability to the process of creating such guidelines.
“Substantially All” Benefits Determination
When determining the limits of a mental health or substance use disorder benefit, the parity test to compare the coverage with relevant physical health benefits should be applied to substantially all medical/surgical benefits in that classification.The rule included this approach, rather than the proposed mathematical test for “substantially all” to implement a less cumbersome option.
“Meaningful Benefits” Definition
To meet the mandatory “meaningful benefits” test, mental health and substance use disorder benefits will be compared with all benefits provided for physical health coverage in the same classification. For this provision, HHS, DOL, and Treasury accommodated our request for this definition to mitigate future coverage disagreements among stakeholders, including plans, providers, auditors, and the courts.
For more details, please see the federal agencies’ joint fact sheet and news release. And please look for additional information in CEO Update this Friday, Sept. 13.
CMS’ Proposed 2025 PFS Rule Would Cut Overall Payments by 2.8%
CMS’ Proposed 2025 PFS Rule Would Cut Overall Payments by 2.8%
In its proposed rule for the calendar year (CY) 2025 physician fee schedule, the Centers for Medicare & Medicaid Services recommends reducing the conversion factor by 2.8% to $32.36 in CY 2025, compared with $33.29 in CY 2024. This change reflects the expired 2.93% statutory payment increase for CY 2024; a 0.00% conversion factor update under the Medicare Access and Children’s Health Insurance Program Reauthorization Act; and a .05% budget-neutrality adjustment.
Proposed New Behavioral Healthcare Services
Released July 10, the lengthy rule includes these proposals to improve payment for and access to behavioral healthcare services:
- For people determined to have elevated suicide or overdose risk, a new payment for safety planning interventions and post-discharge follow-up contacts;
- New digital tools payment for:
- Post-discharge telephonic follow-up;
- Software devices that treat a mental health condition in conjunction with ongoing treatment; and
- Extending evaluation and management services payment to allow clinical psychologists, clinical social workers, marriage and family therapists, and mental health counselors to conduct interprofessional consultations among themselves, as well with psychiatrists and other physicians.
Proposed Payment Updates by Specialty
Table 128 in the proposed rule lists these and other proposed updates by specialty:
- +3.0% for clinical psychologists;
- +1.0% for psychiatrists;
- +4.0% for clinical social workers;
- +1.0% for family practice physicians;
- +1.0% for internal medicine physicians; and
- No change for nurse practitioners.
Opioid Treatment Programs (OTPs)
Telehealth Extended for Methadone Treatment
Regarding methadone treatments, CMS proposes extending current telehealth flexibilities permanently for periodic assessments and initiation of treatment. For beneficiaries lacking permanent access to two-way audio-video communications technology, CMS would allow periodic assessments to be furnished via audio-only communications when applicable requirements are met. To support this proposal, CMS cites evidence that audio-only visits produce many of the same benefits as video-based visits. The rule also notes that this provision would advance the agency’s health equity goals.
For initiation of treatment with methadone for any new patient, audio-visual telehealth may be used if an OTP can conduct an adequate evaluation of the patient. Audio-only telehealth is not permitted. Such telehealth evaluations would use OTP intake add-on code (HCPCS code G2076) and must comply with the Drug Enforcement Administration, the Substance Abuse and Mental Health Services Administration (SAMHSA), and other requirements. These OTP provisions also are intended to align with SAMHSA’s goals for reducing barriers to access.
Payment for Patient Intakes
The rule proposes payment updates for intake activities (HCPCS code G2076) by OTPs, which align with recent SAMHSA reforms to advance patient-centered and evidence-based paradigms of care for Opioid Use Disorder (OUD) treatments such as harm-reduction interventions and recovery support services. Specifically, the rule would implement payment for social determinants of health risk assessments (HCPCS code G0136) to identify unmet health-related social needs or the need for OUD-related harm-reduction interventions and recovery support services. In addition, CMS seeks feedback on how OTPs currently coordinate care and make referrals to community-based organizations that address unmet Health Related Social Needs (HRSNs), provide harm-reduction services, and/or offer recovery support services.
Opioid Agonist and Antagonist Medications
CMS proposes to establish payment for new opioid agonist and antagonist medications that the U.S. Food and Drug Administration approved recently. Specifically, the rule would create a new add-on code to the bundled payment to reflect take-home supplies for nalmefene hydrochloride (nalmefene) nasal spray (Opvee®). The agency also proposes paying for a new extended-release injectable buprenorphine product (Brixadi®), indicated to treat moderate to severe OUD using a new weekly bundled payment code to reflect the weekly formulation of Brixadi®. In addition, the rule would update payment for the existing bundled payment for monthly injectable buprenorphine (HCPCS G2069) in order to reflect payment for the monthly formulation of Brixadi®. CMS’ goals for these changes are to help prevent additional opioid overdose deaths, reduce illicit opioid use, and retain more individuals with an OUD in treatment.
Billing Clarification
The rule also clarifies that for billing, an OUD diagnosis code is required on claims submitted under the Medicare OTP benefit, which helps ensure that payments for Part B OTP services are for the treatment of OUD.
Additional Telehealth Proposals
Permanent Expansion of Audio-only Telehealth
CMS proposes to permanently expand the allowable forms of telehealth “interactive telecommunications systems” to include audio-only communication technology if the patient is not capable of, or does not consent to, the use of video technology.
Temporary Telehealth Expansions
In addition, CMS is proposing temporary changes for the use of audio-visual (not audio-only) telehealth for the purpose of physician/practitioner supervision. Specifically, the rule would expand through CY 2025 the allowance for supervising practitioners to be “immediately available” through audio-visual telehealth. In addition, for CY 2025 only, teaching physicians could continue to supervise audio-visual telehealth services furnished by residents in all teaching settings, such as through a 3-way telehealth visit. Also for CY 2025, the agency will continue to permit physicians to use their currently enrolled practice location instead of their home address when providing telehealth services from home.
The rule also extends through CY 2025 the pandemic-originating coverage of telehealth services provided by federally qualified health centers and rural health clinics. This extension also includes the waiver allowing for reporting of enrolled practice addresses, rather than home addresses, when providers perform services from their home, and the waiver for virtual supervision for residents in all teaching settings when the services are provided virtually.
NABH is displeased that beginning Jan. 1, 2025 – in compliance with federal law – the rule repeals crucial telehealth flexibilities that would subject most digital care to pre-pandemic regulations.
Permanent Audio-visual Telehealth for Low-Risk Services
For services furnished after December 2025, CMS proposes that physician/practitioner oversight via audio-visual telehealth shall be limited to services that are “low risk by their nature, do not often demand in-person supervision, and are typically furnished entirely by the supervised personnel.” CMS’ stated goal for approving remote supervision for these particular low-risk services is that they already are known to balance patient safety concerns with the need to expand access and optimize workforce capacity:
- Services with the underlying HCPCS code that has been assigned a PC/TC indicator of ‘5’; and
- Services described by CPT code 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional).
In addition to CMS’ proposed telehealth expansions, Congress is also considering extending telehealth flexibilities beyond this year, most likely through a two-year extension. NABH strongly endorses these flexibilities.
Quality
For reporting in 2025, CMS proposes six new, optional metrics for the quality payment program.
Please see the agency’s news release to read a high-level summary of the rule. CMS will accept comments on the proposed rule through Sept. 9.
