Position Category: MHAC

Coalition Letter to the Department of Managed Healthcare – Re: Inclusion of Parity Compliance Reviews in Behavioral Health Investigations

May 31, 2023

Mary Watanabe, Director
Department of Managed Health Care
980 Ninth Street, Suite 500 Sacramento, CA 95814-2725

Re: Inclusion of Parity Compliance Reviews in Behavioral Health Investigations

Dear Director Watanabe,

As organizations committed to improving Californians’ access to mental health and substance use disorder (MH/SUD) treatment and ending coverage discrimination against MH/SUD services, we write to express significant concerns about the Department of Managed Health Care’s (DMHC) efforts to determine compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). 1

Based on our previous interactions with DMHC staff and the scope of what was included in the budget change proposal to fund its Behavioral Health Investigations (BHIs), we understood that the DMHC was incorporating robust reviews of parity compliance into its BHIs. However, recent information from the DMHC indicates that the results of MHPAEA compliance reviews from the first round of five BHIs may not be made public and that future BHIs may not include MHPAEA compliance reviews. Because robust MHPAEA compliance reviews are essential to eliminating discriminatory treatment limitations and increasing access to treatment, our organizations request that the Department 1) release the results of all MHPAEA compliance reviews conducted to date and 2) conduct rigorous review of plans’ MHPAEA analyses as part of all future BHIs.

In the 2020-2021 state budget, the DMHC received $2.7 million to conduct BHIs of all full service commercial health plans to “further evaluate health plan compliance with parity and assess whether enrollees have consistent access to medically necessary behavioral health care services.”2 The legislature clearly intended that the DMHC thoroughly evaluate parity compliance as part of the BHIs when it approved the budget change proposal.

Fortuitously, shortly after passage of the budget, Congress amended MHPAEA to require commercial health plans to conduct detailed parity compliance analyses on each non- quantitative treatment limitation (NQTL) in each classification of care (i.e., in/out-of-networkoutpatient, in/out-of-network inpatient, prescription, and emergency).3 Commercial health plans were required to have such analyses, and to provide them to state regulators such as the DMHC upon request, starting on February 10, 2021. These new federal requirements have given the DMHC a powerful mechanism to obtain plans’ NQTL parity compliance analyses, which are the only way to determine whether NQTLs are compliant with MHPAEA.

Given this powerful mechanism at the DMHC’s disposal, we were alarmed that the proposed BHI Technical Assistance Guide (TAG), which was released in November 2021 and contained the information that plans would be required to provide as part of the BHIs, did not include an evaluation of MHPAEA compliance. In providing feedback on the BHI TAG, several of our organizations urged the DMHC to request and thoroughly review each plan’s complete NQTL parity compliance analyses, as well as to collect quantitative comparative data on plans’ coverage of MH/SUD and physical health services. Based on this request, our organizations were grateful that DMHC contracted with national MHPAEA experts to help conduct the BHIs, including collecting and analyzing plans’ NQTL parity compliance analyses. Our understanding is that, in its first five BHIs, the DMHC has requested and reviewed with expert assistance these plans’ NQTL parity compliance analyses.

Yet, recently, we have reason to believe that the results of the NQTL parity compliance analyses reviews may not be included in the public BHI findings. Any failure to release the results of the parity compliance reviews as part of the public BHI findings would be deeply disturbing, particularly in light of our state’s ongoing MH/SUD crisis and the widespread parity non- compliance being uncovered by other state and federal regulators.

For instance, in the Biden Administration’s 2022 MHPAEA Report to Congress, the Departments of Labor, Health and Human Services, and Treasury found that all health plans’ NQTL parity compliance analyses failed to demonstrate compliance. Common parity violations included limitations on autism services, limitations on medications for opioid use disorder, and prior authorization requirements.4

Other states have similarly found widespread non-compliance. For example, the Illinois Department of Insurance has issued numerous fines for parity violations based on their review of plans’ NQTL parity compliance analyses.5 New York State has similarly found broad noncompliance, issuing fines and determining that health plans have broadly failed to demonstrate compliance with MHPAEA. 6

Investigations that do not examine and report on plans’ compliance with MHPAEA are fundamentally flawed and incomplete. And reviewing plans’ NQTL parity compliance analyses must be the backbone of determinations of MHPAEA compliance. Furthermore, California must not attempt to rely on federal regulators to enforce MHPAEA. Federal regulators review only a small subset of plans’ NQTL parity compliance analyses, and the primary federal regulator only has 1 investigator for every 12,500 plans. Congress recognized the primary role of state insurance regulators like the DMHC in enforcing MHPAEA when it required state-regulated plans to provide their NQTL parity compliance analyses to these regulators upon request. Californians deserve to have the DMHC conduct robust oversight to protect their rights. Therefore, we call upon the DMHC to release complete summaries of all reviews conducted of plans’ NQTL parity compliance analyses when it releases the results of the BHIs. Furthermore, it is critical that the DMHC request and review plans’ NQTL parity compliance analyses as part of all future BHIs, since no investigation of Californians’ access to MH/SUD services can be complete without a thorough review of parity.

We would welcome the opportunity to discuss how the DMHC is incorporating robust reviews of plans’ NQTL parity compliance analyses into the BHIs. If you have any questions, please do not hesitate to reach out to Lauren Finke (lauren@thekennedyforum.org).

  • 1 MHPAEA is incorporated into California law in Health and Safety Code Section 1375.76.
  • 2 DMHC Announcement on its Behavioral Health Focused Investigations, August 26, 2021. https://www.dmhc.ca.gov/Portals/0/Docs/OPM/Health%20Plan%20Changes_2021-08-26.pdf
  • 3 The NQTL parity compliance analyses requirements, which were enacted as part of the Consolidated Appropriations Act, 2021, are located at 42 USC 300gg-26(a)(8).
  • 4 https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/report-to- congress-2022-realizing-parity-reducing-stigma-and-raising-awareness.pdf.
  • 5 See, for example: https://www.illinois.gov/news/press-release.25897.html. 6 See, for example: https://www.dfs.ny.gov/reports_and_publications/press_releases/pr202112141#:~:text=The%20overall%20DFS% 20monetary%20penalty,the%20Behavioral%20Health%20Ombudsman%20Program and https://omh.ny.gov/omhweb/bho/docs/nys-mhpaea-report.pdf.

Sincerely,

Lauren Finke
The Kennedy Forum

Robb Layne
California Association of Alcohol and Drug Program Executives

Adrienne Shilton
California Alliance of Child and Family Services

Cathy Atkins
California Association of Marriage and Family Therapists

Chad Costello
California Association of Social Rehabilitation Agencies

Le Ondra Clark Harvey
California Council of Community Behavioral Health Agencies

Jennifer Alley
California Psychological Association

Paul Yoder
California State Association of Psychiatrists

Kimberly Andosca
California Society of Addiction Medicine

Heidi Strunk
Mental Health America – California

Karen Fessel, Dr. PH
Mental Health and Autism Insurance Project

Jessica Cruz, MPA/HS
National Alliance on Mental Illness (NAMI- CA)

Paul Kumar
National Union of Healthcare Workers

Randall Hagar
Psychiatric Physicians Alliance of California

Corey Hashida
Steinberg Institute

AB 874 (WEBER) Healthcare Coverage Out-of-Pocket Expenses – Support

April 6, 2023

The Honorable Dr. Akilah Weber
State Capitol
P.O. Box 942849
Sacramento, CA 94249-0079
Tel: (916) 319-2079

RE: Support for AB 874 (Weber)

Dear Assembly Member Weber:

Mental Health America of California (MHAC) is pleased to support Assembly 874 (Weber), legislation which would require a health care service plan, health insurance policy, other health coverage carrier, or pharmacy benefit manager that administers pharmacy benefits to apply any amounts paid by the enrollee, insured, or another source pursuant to a discount, repayment, product voucher, or other reduction to the enrollee’s or insured’s out-of-pocket expenses toward the enrollee’s or insured’s overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or applicable cost-sharing requirement under the enrollee’s or insured’s health care service plan, health insurance policy, or other health care coverage.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services.

The rising cost of medical care puts many people in a life-threatening position to refuse services and support out of fear of inability to pay. Even with insurance, the out-of-pocket costs for medication can cause an undue burden. While the use of discounts, product vouchers, and other copay support systems are used to alleviate the financial burden, insurance companies sometimes do not count those forms of payment towards the overall out-of-pocket maximums, forcing the insured to pay more for medicine or services. Assembly Bill 874 will make those indirect copayments count towards the maximum out-of-pocket expenses. This will improve access to medications and remove financial barriers for people with mental health challenges.

For these reasons, we support Assembly Bill 874. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org.

In Community,

Heidi Strunk
President & CEO
Mental Health America of California

SB 472 (HURTADO) Opioid Overdose Reversal Medication – Support

April 4, 2023

The Honorable Melissa Hurtado
California State Senate
1021 O Street, Room 7310
Sacramento, CA 95814

RE: Support for SB 472

Dear Senator Hurtado:

Mental Health America of California (MHAC) is pleased to support SB 472 (Hurtado), legislation which would require school districts, county offices of education, and charter schools to maintain at least 2 doses of naloxone hydrochloride or another opioid antagonist for purposes of those authorizations and report information regarding naloxone hydrochloride or other opioid antagonists to the State Department of Public Health, Department of Education, and parents or guardians of pupils.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services.

Senate Bill 472 will ensure our schools are prepared to protect our youth in the event of an overdose. With the dramatic increase in Fentanyl poisoning, we know youth are now more susceptible and at risk. Youth who experience overdose can just as easily be first-time or infrequent users as individuals with a substance use issue. Requiring K-12 schools to maintain naloxone on campus will save countless children and youth in California. In addition, the use of these preventative measures will be reported to the state and to parents or guardians, granting full transparency about what is happening in our local community.

For these reasons, we support Senate Bill 472. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org.

In Community,

Heidi Strunk
President & CEO
Mental Health America of California

SB 509 (PORTANTINO) School Employee and Pupil Training and Education – Support

April 4, 2023

The Honorable Anthony J. Portantino
California State Senate
1021 O Street, Suite 7630
Sacramento, CA 95814

RE: Support for Senate Bill 509 (Portantino)

Dear Senator Portantino,

Mental Health America of California (MHAC) is pleased to support Senate Bill 509 (Portantino), legislation which would require the Department of Education to identify training programs that instruct on recognizing the signs and symptoms of youth behavioral health disorders such as schizophrenia, bipolar disorder, major clinical depression, and anxiety disorders. In addition, the bill would require 75% of a local education agency’s classified and certified employees, who have direct contact with pupils at school, receive behavioral health training. Furthermore, it would require pupils to receive evidence-based, age-appropriate mental health education from instructors trained in the appropriate courses at least once in elementary school, at least once in junior high school or middle school, and at least once in high school.

MHAC is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services.

Teaching our youth about behavioral health in addition to having trained school employees to recognize the signs of behavioral health challenges is key to providing the best services and support in our schools. Behavioral health challenges can start at a young age and, when recognized, can be addressed with support and services that foster healthy child and youth development. Senate Bill 509 could help our youth self-identify behavioral health challenges and seek help due to the consistent behavioral health education from elementary through high school. It also trains our school personnel to be able to recognize the signs associated with behavioral health challenges, informing them of the best way to help.

For these reasons, we support Senate Bill 509. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org. I

In Community,

Heidi Strunk
President & CEO
Mental Health America of California

AB 19 (PATTERSON) Opioid Antagonist – Support

March 29, 2023

The Honorable Joe Patterson
State Assembly
1021 O St., Suite 4530
Sacramento, CA 95814

RE: SUPPORT Assembly Bill 19 (Patterson)

Dear Assembly Member Patterson:

Mental Health America of California is pleased to support Assembly Bill 19 (Patterson), legislation which requires each school to have no less than two doses of naloxone onsite to be available to aid persons suffering from an opioid overdose.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services. Along these lines, we support efforts which increase access to voluntary, culturally responsive, community-based behavioral health services.

Assembly Bill 19 will ensure our schools are prepared to protect our youth in the event of overdose. With the dramatic increase in Fentanyl poisoning, overdoses can happen with the ingestion of a single pill. Youth who experience overdose can just as easily be first-time or infrequent users as individuals with a substance use issue. Requiring K-12 schools to maintain naloxone on campus has the potential to save the lives of countless children and youth in California.

For these reasons, we SUPPORT Assembly Bill 19. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org. In Community,

Heidi Strunk
President & CEO
Mental Health America of California

SB 250 (UMBERG) Fentanyl Self-Reporting Immunity – Support

March 29, 2023

The Honorable Tom Umberg
State Senate
1021 O St., Suite 6530
Sacramento CA 95814

Re: Support for SB 250 (Umberg)

Dear Senator Umberg:

Mental Health America of California is pleased to support Senate Bill 250 (Umberg), legislation that expands California’s 911 Good Samaritan law to include self-reporting of fentanyl poisonings and opioid overdoses to law enforcement and medical assistance through fentanyl testing strips and other medical devices such as smart watches.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services. Along these lines, we support efforts which increase access to voluntary, culturally responsive, community-based behavioral health services.

Overdoses frequently occur when an individual ingests a pill or other substance that has been laced with fentanyl. SB 250 will encourage the use of fentanyl testing strips by eliminating the criminalization that would otherwise result from the individual’s reporting of the fentanyl adulteration. In addition to guaranteeing that people receive help and not handcuffs, SB 250 provides an opportunity to get Fentanyl off the street and decrease further poisonings or overdoses from occurring to themselves and their community.

For these reasons, we support Senate Bill 250. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org.

In Community,

Heidi Strunk
President & CEO
Mental Health America of California

AB 236 (HOLDEN) Ghost Network Prevention – Support

March 29, 2023

The Honorable Chris Holden
California State Assembly
P.O. Box 942849
Sacramento, CA 94249-0041

Re: AB 236 (Holden) SUPPORT

Dear Assemblymember Holden:

On behalf of Mental Health America of California, I am writing to express our strong support of AB 236 (Holden), which would put an end to ‘ghost lists’ and rampant insurance provider list inaccuracies by reinforcing current policy with accuracy guidelines, benchmark goals, and effective enforcement methods.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services. Along these lines, we support efforts which increase access to voluntary, culturally responsive, community-based behavioral health services.

Although California has strong laws and regulations regarding the accuracy of provider health plan directories, these laws are not adequately enforced. People in need of mental health services are routinely provided with outdated provider lists that are grossly inaccurate, with numerous providers listed who are unavailable to see new clients for a variety of reasons. This results in significant challenges and delays for people in need of behavioral health care in obtaining that care.

AB 236 would require health plans and insurers to annually audit their provider directories and remove inaccurate listings, with accuracy benchmarks beginning with 60% accuracy on January 1, 2024, increasing annually to reach 95% accuracy by January 1, 2027. Additionally, this measure would subject plans and insurers to penalties for failure to meet these benchmarks and for inaccurate listings in a provider directory. These enforcement provisions will result in meaningful improvements in access to care for Californians with behavioral health needs.

For these reasons, Mental Health America of California is in strong support of AB 236.

If you have any questions, or if MHAC can provide assistance on this bill or any other behavioral health legislation, please do not hesitate to contact me or our Interim Public Policy Director, Karen Vicari (kvicari@mhaofca.org).

In Community,

Heidi L. Strunk
President & CEO

SB 857 (LAIRD) Advisory Task Force on LGBTQ Pupil Needs – Support

March 29, 2023

The Honorable John Laird
California State Senate
1021 O Street, Suite 8720
Sacramento, CA 95814
Phone: (916) 651-4017

RE: Support for SB 857 (Laird)

Dear Senator Laird:

Mental Health America of California (MHAC) is pleased to support Senate Bill 857 (Laird), legislation which would require the Superintendent of Public Instruction to convene an advisory task force to identify the statewide needs of lesbian, gay, bisexual, transgender, queer, questioning, and plus (LGBTQ+) pupils and to assist in implementing supportive policies and initiatives to address LGBTQ+ pupil education.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services.

When curriculum, policy, strategic plans, or general decision-making in education occurs, it is important we take into consideration the perspectives of our most underserved and disproportionately impacted communities. Providing a space to be a part of the decision-making process guarantees the inclusion of those perspectives in the process. For our LGBTQ+ community, many supports and services don’t provide adequate care or address basic needs to live full and productive lives. SB 857 not only works to identify what those needs are for this community, but requires the LGBTQ+ community to be a part of the task force which is making the identifications and recommendations.

For these reasons, we support Senate Bill 857. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org. In Community,

Heidi Strunk
President & CEO
Mental Health America of California

SB 287 (SKINNER) Social Media Safety for Youth – Support

March 28, 2023

The Honorable Nancy Skinner
California State Senate
1021 O St., Suite
Sacramento CA 95814

Re: Support for Senate Bill 287

Dear Senator Skinner:

Mental Health America of California is pleased to support SB 287, legislation designed to hold social media platforms accountable for promoting the illegal sale of fentanyl to California youth and for the sale of unlawful firearms, including ghost guns, via social media platforms. The protections in SB 287 would also hold these platforms accountable for targeting other harmful content toward youth that could result in suicide, eating disorders, dangerous dieting practices, or inflicting harm on themselves or others.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services.

We oppose the dangerous algorithms of social media platforms that direct users, including children and youth, to harmful and dangerous content. Unregulated social media platforms have increased youth access to weapons, substances, and harmful content which has been life threatening for our youth. Senate Bill 287 takes a bold step to hold social media platforms accountable for their part in intermediating illegal activity and life- threatening youth trends.

For these reasons, we support Senate Bill 287. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org.

In Community,

Heidi Strunk
President & CEO
Mental Health America of California

SB 11 (MENJIVAR) CSU Mental Health – Support

March 24, 2023

The Honorable Caroline Menjivar
State Senate
1021 O St., Suite 6720
Sacramento CA 95814

Re: Support for Senate Bill 11 (Menjivar)

Dear Senator Menjivar:

Mental Health America of California is pleased to support your bill, Senate Bill 11, legislation that would place certain restrictions on the contracting out of mental health services provided by the California State University (CSU) system, as well as require oversight of the campus mental health services provided. This bill would also require the CSU to hire additional full-time, permanent mental health counselors to address increased student needs and work to create a pipeline for CSU students to become mental health professionals.

Mental Health America of California (MHAC) is a peer-run organization that has been leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to ensure that people of all ages, sexual orientation, gender identity or expression, language, race, ethnicity, national origin, immigration status, spirituality, religion, age or socioeconomic status who require mental health services and supports are able to live full and productive lives, receive the mental health services and other services that they need, and are not denied any other benefits, services, rights, or opportunities based on their need for mental health services. Along these lines, we support efforts which increase access to voluntary, culturally responsive, community-based behavioral health services.

People using community-based resources deserve the highest quality of mental health services and supports. For our youth, college campuses often provide these services through a third party which has the potential to impact the quality of care. Campuses that contract services out are not able to directly address complaints, specialized training, or diversification of staff. This bill looks to hold campuses accountable and increase the quality of care while also providing a career pathway for youth to become mental health professionals. Additionally, SB 11 will significantly increase access to much-needed mental health services on CSU campuses by increasing the provider to student ratio.

For these reasons, we support Senate Bill 11. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org. In Community,

Heidi Strunk
President & CEO
Mental Health America of California