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 ofÂ 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:
- Equity in financial requirements. Deductibles, co-payments, coinsurance, and out-of-pocket expenses must be the same for medical and mental health conditions covered by the plan.
- Equity in treatment limits. 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.
- Equality in out-of-network coverage. 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.
Let me outline some recommended steps:
1- Prepare a series of sample letters that your patients and also providers can send to insurance plans. You will need several types of letters:
(a) one for an initial request for coverage. This initial letter should have a brief overview of EEG Neurofeedback and the evidence behind it. Any controlled (not just random assignment) study, expert consensus panels or even non controlled case studies are valid. Further it would be helpful to identify if any non US countries are paying for EEG biofeedback ( and if those countries have done a tech assessment then referencing that) as well as listing those US insurance companies that are currently reimbursing;
(b) if coverage is denied a letter requesting the reason for denial and based on the reason for denial then other other types of sample letters will be needed;
(c) if the denial is because EEG biofeedback is still considered experimental then a sample letter should be prepared that will ask for 1 the Neurofeedback technology assessment that this decision is based on and two the scientific criteria used for Medical treatments and evidence that these criteria are used for the majority of Medical treatments;
(d) If the reason for denial is that the Insurance company states that they agree that EEG Neurofeedback is non experimental but they are not required under the Parity Law to fund any treatment they don’t want to (i.e. scope of service parity issue) then another type letter needs to be prepared.
2- 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.
3- 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:
- Preemptive Letter for In-Network
- Preemptive Letter for Out-of-Network
- Appeal Letter for In-Network Appeals
- Appeal Letter for Out-of-Network Appeals
- Spreadsheet for tracking Health Plans responses to letters
- Authorization for Release of Information from Health Plan
- Email Script Example
- Telephone Script Example
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.