Payment Parity for Behavioral Health

Anna Whites, Owner, Anna Whites Law Office, speaks to Trinidad Navarro, Insurance Commissioner, State of Delaware, and David Lloyd, Senior Policy Advisor, The Kennedy Forum, about payment parity for behavioral health services. The podcast looks at Delaware’s recent audits of insurance companies for mental health payment parity, work done by the Kennedy Forum on parity oversight, and enforcement actions. The speakers also talk about what health care lawyers should do to advance parity and ensure access to mental health services. From AHLA's Behavioral Health Task Force.

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Transcript

Speaker 1: 0:14

Hello, I'm Anna Whites. I'm the owner of Anna White's law office in Frankfurt, Kentucky, which is our state's teeny weeny state capital. I have a healthcare practice, and the bulk of what I do is in behavioral health, mental health care. So I spend a lot of time talking about parity. Uh, parody is the paying a provider who renders mental health, healthcare, or behavioral healthcare or substance abuse care, an equivalent sum to a provider who's rendering physical healthcare in Kentucky. We are a very rural state, and so a lot of our population is remote from their healthcare providers, and we're also a very low income state. So Medicaid pays for healthcare for a significant number of Kentuckians. In Kentucky, we have five, uh, MCOs managed care organizations, and they all cover the whole state. So it's very often true that even a small practice will have all five MCOs covering some of their patients. And so a huge part of what I do is fight with the MCOs over what is being paid by each Medicaid managed care organization. For a Medicaid patient, you can have five different reimbursement rates for behavioral health, healthcare in one practice, and then physical healthcare paid exactly the same by all five. And so, um, since this is a huge topic on my mind, I reached out. I am the American Health Law Association's Behavioral Health Task Force Programming Chair, and we talk on the task force every month about, uh, behavioral health across the nation. And parody is a topic that's at the forefront of everyone's minds. So I reached out to two huge experts in the field, no pressure gentlemen, uh, to talk with me this afternoon, and I'll let them introduce themselves. Trinidad, tell us about yourself.

Speaker 2: 2:18

Hi, uh, well, good afternoon. Uh, my name is Trinidad Navarro. I'm the insurance commissioner for the state of Delaware. And before I begin talking about myself for a few moments, I just want to thank you Ms. Whites, for what you do. Um, and, uh, we recognize in Delaware how important it is the role that you serve. Uh, we're, there's a, a dearth of, uh, physicians or, uh, practices here in our state for, uh, folks who treat mental health and substance abuse issues. Um, so, uh, we know what you do, and we are grateful, and we wish there were more people like you. So just wanted to to share that with you real quick. Um, my name again is Trinidad Navarro. Please don't hold that against me. I was unconscious when my father named me that. Um, it's<laugh>, it's a unique name. It's one that, um, it's a, it's a family name and, um, it's one I'm very proud of. Uh, I serve as the Insurance Commissioner, which is sort of the largest consumer, uh, advocacy agency in this, in the state of Delaware for years now. Uh, I'm in my fifth year. I've worked to increase, um, insurance affordability and availability for residents, um, and businesses alike, um, while at the same time holding insurance companies accountable for fulfilling their obligations. So we, we work really hard every day to try to protect, uh, educate and advocate for Delaware, uh, residents and everything from, uh, auto insurance to homeowner's insurance, uh, life products, annuities, things of that nature. And, uh, really everything in between and our duties are really broad. Um, you know, every, every once in a while I'll pick a new project, uh, from our state legislature or introduce a new project, uh, to them. And one of those, which, you know, I'm really passionate about is, uh, ensuring mental health parody. Uh, so, uh, I, I know we ask some questions and I'll be happy to, to, to take some of those in just a few minutes. I just wanna say it's, uh, uh, to honor to be here. And I, I think it's my job to now introduce our, our third speaker, uh, Mr. David Lloyd.

Speaker 3: 4:24

Well, thank you, uh, commissioner Navarro. Um, it's, it's great to be, you know, with everyone today. Um, I'm David Lloyd, the Senior Policy Advisor, uh, with the Kennedy Forum, uh, which was founded by former congressman, uh, Patrick Kennedy after he left, uh, Congress. Um, and, uh, Patrick Kennedy's author of the Mental Health Purity and Addiction Equity Act, uh, the landmark Federal legislation that prohibits, uh, discrimination and health insurance, uh, coverage, and, you know, broadly applies to both commercial health insurance and also, you know, Medicaid, uh, manage care. Um, and so a lot of the work that the Kennedy Forum is focused on, uh, is advancing, you know, mental health, uh, and addiction equity, uh, through enforcement of the Federal Parity Act. Um, and really this is all about, uh, you know, making sure that people have, uh, access to services when they have health insurance coverage, um, and that, um, you know, they're getting the services that they're entitled to, uh, under the law. Um, because we see that when, you know, insurers, you know, wrongly deny these services, um, uh, either two things happen. Either people don't get the care that they need, um, or they have to pay out of pocket. And oftentimes this can be, you know, really ruin as sums of tens of thousands of dollars, depending on the level of care, which is simply, you know, out of, uh, uh, out of the ability of most Americans to pay. Um, so we continue to see access, uh, as a huge problem, particularly right now with covid. Um, and parity is an essential part of addressing, uh, these fundamental mental health, uh, access issues, um, which is why we focus on it. So, uh, very happy to be here to discuss more about these issues. Uh, you know, thank you, uh, Anna for the invitation and look forward to discussing, uh, more about, uh, parity, uh, and mental health equity.

Speaker 1: 6:19

Wonderful. Thank you. And I'm so grateful you two chose to join us today. Um, my first question, Trinidad, I've been watching what Delaware is doing, and Delaware has done a lot of work recently auditing, uh, behavioral health parody, looking at the insurers in your state and determining whether parody is actually being enforced. Can you tell us about that, um, what you're doing, uh, particularly how it came to your attention and what you found out in your initial audits?

Speaker 2: 6:51

Sure. Uh, to sort of, uh, segue from what, uh, David had mentioned, um, you know, fighting for having insurance companies fulfill their obligations for mental health treatment, just like any other issue, um, you know, this is what insurance commissioners across the country do. When we find out of, of, uh, issues that people are facing, many times people don't know what's in their policy. Many times they don't know where to turn when they've been denied or, or they've been, um, they're in treatment and for some reason, a, a computer program or an algorithm tells them their, their time is up, and that their, uh, the treatment is over without, uh, physician making that, uh, determination. So many, many times, we step in for the consumer. You see, the, in insurance companies certainly don't wanna be on our bad side, and a lot of times just a phone call from our office is enough. Uh, but the truth is that we can't hear from every person who's, and, uh, quite frankly, not every person knows who to turn to. So, we, um, have been working toward a, a, a more just healthcare system over the past decade. And mental health parody has been a, a key solution to the issues of access and affordability that plague our community. So in 2018, we passed Senate Bill two 30, which was a huge, uh, uh, step in the fight. And, um, what senate Bill two 30 did was insured or required insurers to submit an initial analysis to our mental and behavioral health coverage, um, uh, analysis of how they cover mental and behavioral health coverage to our department in 2019, after which our team would, um, would do a, uh, compliance reviews in our, uh, annual market conduct examinations. And, um, what what we found was, what we knew there would be a number of violations, because this was our first run at this. And, uh, we found significant ones, uh, with our two largest employers or insurers, um, uh, Highmark and Aetna. Uh, we still have two, uh, insurance companies, three actually, that were still in the process of finishing up the examination. But, uh, we found in those exams that, um, uh, thousands of violations and it's re resulted in just under$600,000 in fines, total fines so far. And, um, part of those, uh, fines are also changes that, uh, were requiring them to do, uh, so that they improve on their processes and procedures. And, um, you know, we, we did again, expect to see a large number. And with the other smaller insurers, uh, they're proportionate number as well as far as, um, the types of violations that we found. So we, some of the, I'll just give you a quick a recap of some of the violations we found, uh, disparate, uh, pre-authorization requirements, uh, I mentioned this earlier, but having limits on the scope or duration of benefits, uh, and, uh, pharmacy requirements that were different from, or different from, uh, those seeking non behavioral healthcare. And, uh, you know, these are just a few of the, the violations we found, and they're, the corrections are being made, and we're watching closely to make sure that they, uh, you know, they follow up on those and we follow up on those as well. So once those other companies are completed, we'll, um, we'll let the public know, uh, when those exams are, are done. But we have, uh, we've seen, again, thousands of violations. And, you know, this is something that is troubling, but not unexpected. And, um, you know, I, I attend, uh, um, uh, behavioral Health consortium meetings, and I've, I've heard time and time again from both physicians and people seeking treatment of these issues. Um, so that, I guess, if you remember anything, I talk about, uh, myself and all the commissioners across the country, this is what we do. And this is the, uh, although it's a terrible situation for people, it's the best part of the job is, uh, stepping up and helping people who are, um, who need the help most.

Speaker 1: 11:08

And that's good to hear, because sometimes when I'm filing complaints with the Department of Insurance or, or speaking somewhere and saying, this is what's happening, somebody has to change it. Um, I feel like maybe I'm just being an annoyance. Maybe I'm not being a pest. And I'm not sure, even in my position, I was aware that they were very detailed audits that the insurance commissioners do. And, and as you're doing to really track down why the complaints are occurring and find the solutions to those. And, and while fines are vital, it's exciting to me that you're going beyond just a snack on the rest, even if that's a substantial smack and going to corrective action plans and making sure that, that these are remedied. So that, that's very exciting.

Speaker 2: 11:55

Yeah. Well, thank you. And I tell you, we get calls on the weekends, holidays, we got calls over. I, I received a call over the, um, Christmas holiday on Friday, um, the day after Christmas or Saturday, the day after Christmas, that, that weekend. And, uh, by Sunday, we had the issue resolved. And, you know, I'm fortunate to have a staff that, you know, we, we sort of have a culture in our offices that, uh, you know, we treat people like we would treat our family. And, uh, that has worked out very, very well for us.

Speaker 1: 12:24

And that's wonderful. Uh, as a nation, we need to really recognize the importance of behavioral healthcare, mental healthcare, and reduce that stigma and increase that access and make sure reimbursement is fair. Uh, David, you talked a little bit about, um, starting with the big picture and parody and coverage, um, and what you do to make sure parody is a reality for all of us. Um, talk a little bit about in your day-to-day life, uh, what are you doing on your end to enforce parody for mental and behavioral health?

Speaker 3: 13:00

Well, let me first of all just, you know, start out by congratulating Commissioner Navarro on what Delaware has done. Um, they really had been at the forefront of parody with SB two 30, which was passed at several years ago. Um, and doing these types of reviews, um, frankly, all states should be doing what, uh, what Delaware is doing. And it's, it is amazing, and it shows you kind of where we are that they have found, you know, thousands of violations, um, uh, that, uh, you know, the, the violations were the kind of that, that extensive. And I think for too long, we've kind of accepted that mental health and substance use disorder coverage is just gonna be substandard. Um, and we've, uh, often relied on, on government programs to pay for mental health services, even for, um, uh, populations that are commercially insured. We see folks, um, you know, transition them to Medicaid, um, you know, once they lose employment because of their conditions. Um, you know, we also see that, um, uh, the people have to go out of network far more often for behavioral health services, um, than they do for physical health services. And Millman, uh, did a report, uh, a couple reports now over the last few years showing that this is, you know, uh, patients have to go five to 30 times, uh, more often out of network for behavioral health, uh, services. So, uh, it's really a way that, uh, that care is rationed because out of network services are more expensive, uh, you know, by their very nature. Um, so, you know, we've been looking at, uh, how we enforce the parody Act, um, and how we integrate, um, you know, mental health and addiction, uh, reimbursement, uh, into our healthcare financing system in an equitable way, um, which does mean, uh, you know, enforcement of the Federal Parody Act. And it means doing exactly what states, uh, you know, like, uh, Delaware are doing. It means collecting information on states, uh, you know, state's comparative compliance analyses and make sorry on plans, comparity, uh, parody compliance analyses, and making sure that plans are demonstrating, uh, their compliance. Um, and what Delaware really set off was a nationwide, uh, what's turned into a real movement with now 20 states requiring, uh, plans to submit parity, compliance analysis. You know, like Delaware, uh, was, uh, I believe the first, uh, to actually do. Um, and so that's having a real effect with more, more enforcement actions, uh, across the country. I don't think there's a major insurer who has not been, uh, you know, found to have been in violation in one way or another, uh, across the country. Um, and Congress actually just took the same standards that are in, uh, in the Delaware statute and, uh, you know, wrote it directly into the Public Health Services Act and, uh, you know, into erisa, um, you know, for all, all basically all commercial plans, uh, nationwide, that they have to be conducting these parity compliance analyses and the Department of Labor, um, can request, um, these analyses, uh, you know, whenever, whenever it requested plans have to, uh, basically show that they're in compliance, uh, you know, by, uh, you know, handing over these analyses and, and state insurance commissioners and the other states that don't have the requirements already in place, uh, can now also request those information. So, um, really, uh, there's been a sea change in making sure that we're putting the onus on plans to demonstrate their compliance, uh, and not on consumers, um, to try and fight, uh, denials kind of after the fact. Um, the other thing that we are working on right now, um, which, uh, is really to strengthen parity laws, um, in California, uh, the Kennedy Forum and our partners, uh, the Steinberg Institute, um, uh, you know, took a landmark, uh, uh, lawsuit, uh, out of the, uh, uh, federal court in California, uh, called Whit versus United Behavioral Health. Um, and basically put standards that were identified in that court decision, um, you know, into a new California law, which just took effect. And essentially what this landmark court ruling, uh, found was that United Behavioral Health, um, was using clinical review criteria that were inconsistent with generally accepted standards of care, um, and used those to deny mental health and addiction coverage to more than 50,000 members across the country, uh, half of whom were children and adolescents. Um, and then the court actually described what these generally accepted standards for mental health and addiction care are, um, in order United, uh, to use nonprofit Clinical Specialty Association, uh, medical necessity criteria, um, uh, from groups like the American Society of Addiction Medicine. So essentially, the new law that we enacted in California puts many of these standards in place. We now have model legislation that we're pushing across the country, um, called the Ramstad, uh, model State Parity Bill, uh, which is named after former congressman, uh, Jim Ramstad, who is co-author of the Federal Parity Act with Patrick Kennedy, uh, and who passed away, uh, in, in November. Um, so, you know, a lot of things moving forward and trying to make sure that we are really focusing in on equity, uh, in mental health and addiction coverage. Cause that's ultimately the goal. Um, because without equity, we certainly won't have access.

Speaker 1: 18:26

You're doing amazing work, both of you, and, and I know Delaware is, is a huge leader in the field. I think all of us have seen what you've done over the last couple years and, and just been in awe of Delaware. Um, I know in my work, and a lot of our audience today are going to be behavioral health providers and attorneys who work with them. And we see now in Kentucky, because there have been some demands, obviously parody, you have to say, yes, I am paying X dollars for this service. Um, but when you look at the income coming in, even though the, the fee schedule says, we'll pay 60 bucks, what the provider's getting is 20 or, or 30 or less. And I've seen a real reluctance both on the patient side and on the provider side to strongly advocate for fair reimbursement, full payment, and full coverage, rather than it being chipped away because we didn't like what you did here or there. Um, behavioral health providers seem to still feel tenuous about what they provide, and that they're afraid the payers are gonna look at them. I've literally had it physicians say to me, but they'll hate me. They'll, they'll retaliate if I push them. And so, um, it, it's good to hear that this is happening nationwide and that there are resources that they can reach out to and rely on to, to demand that parody, because until we get full and complete payment from a full and complete network, we, we really haven't, uh, addressed the access issue. So, um, I'll pro this to both of you, and we'll start with the commissioner. What should lawyers who represent the payers or the providers in the behavioral health space do to help advance parity, to help make your job easier? Um, and also our ultimate goal to make sure that everyone with a mental health condition gets the care they deserve.

Speaker 2: 20:25

Well, you know, I, I just wanted to back up real quick and touch on the comments you made about, you know, you, you've heard that, uh, providers and others were concerned that, uh, insurers would retaliate against them, uh, for reporting it to the issues to us. And I've heard that time and time and time again. Uh, this is real. Um, and the one, one thing that if I could provide some comfort, uh, if we find out that that's happening, um, we'll put it into that as well. You see, what can, what can lawyers do, uh, or people who represent you do to help us, uh, as regulators, um, document, document, document. Um, instead of sending us maybe, uh, an issue with, uh, patient X, send us a document with patient A through Z. In other words, if this is how we identify, uh, the companies are, are conducting prohibited practices, and that is through, uh, consumer, uh, complaints. And, um, you know, it's, and this is from, this is really from all, uh, lines of insurance, but particularly with, uh, with health insurance, when we find out that, uh, you know, one company is, is, is worse than another, and believe me, we have found that in this scenario, and I won't throw any one company under the bus, but you know, just from, from Delaware, you know, and I talk to providers, they say this, this company, you know, it's called company access is a real problem. And so we've made it crystal cleared to them. Uh, we have, uh, followed up with them and, uh, we continue to do, uh, these market conduct exams. And that's what's so great about, uh, Senate Bill two 30 is that, you know, it allows us, we would do it anyway, um, the exams, but it makes it crystal clear what the, uh, the insurers and the, and the, the, the have to fulfill their obligations in a manner, um, that is compliant with our als. And, and like we mentioned earlier, they were not. And, uh, there are significant penalties associated with that. And then when we hear from, uh, uh, the folks who represent the industry, uh, we, that's how we identify patterns as well. And, and, and two, you know, not that I, I, I, I'm certainly not in the practice of, of, um, speaking up or flying a flag for insurers, but in, in some cases, uh, because this was, I guess, considered a new bill in 2019, in 20, uh, 20 18, 20 19, um, they were like, well, we didn't know. And, um, certainly that's not an excuse, but we're able to direct them in the right direction. And that's the ultimate goal, is that, uh, you know, um, they comply with the par laws, and we don't have these, these issues going forward.

Speaker 1: 23:10

And I know, um, I've actually had attorneys for payers say to me, but Anna, particularly in the substance abuse area, this carer is really, really expensive though, Anna, we, we just can't afford it. And there's a fear also on our side, the the lawyer side that will push too hard on an insurance company, and they'll just say, fine, it's too expensive. We're not doing it anymore. We'll leave your state. Um, and certainly with commercial payers where they have more flexibility, um, we've seen them say, well, we, we just don't want to cover any mental health at all. We'll only take a population that doesn't have mental or behavioral health issues. And to me, that's scary because I'm depriving potentially patients or doctors of, of their care or their living. Uh, do you address that as well? Yeah,

Speaker 2: 24:01

I mean, that is, I, I can understand that would be scary. Um, but, but what I will tell you is a lot of times that's just, just to quote President Biden malarkey in that, uh, they're not leaving the state. Uh, they have a, they're, they're in the state because they're, they're, they're turning a profit and, uh, they're just, uh, they pack up and go, we, we have seen that, uh, years ago that dealt specifically with the aca, but that's really because the, the, the company at the time was he hemorrhaging, you know, hundreds of millions of dollars. And, um, they, they had to go, I mean, this, they couldn't afford to, to continue to lose money like that. But other insurers, uh, that are established that have been around a long time, and whichever state it is not easy to, to pick up and go. And then, um, when they realized that they were actually turning a profit and wanna come back, uh, you know, then they, they've lost customers. They have to start, you start from, um, uh, from scratch. And it's, it's never easy for them to do. And it's a lot of times when they say that, you can tell them that Commissioner Navarro said, that's malarkey

Speaker 1: 25:05

<laugh>. Okay. I'll, and David, uh, on your end is, is that a realistic fear or something that you hear that an insurance company will leave or retaliate that they'll be harm to patients or providers who raise concerns?

Speaker 3: 25:19

You know, I don't think that's a realistic fear. I mean, you know, all the data shows that mental health parity didn't, you know, increase, uh, increased premiums. And, you know, even more importantly, there's been some, uh, you know, some new data relating to, you know, what drives healthcare costs. Um, and a lot of healthcare costs are driven by people with behavioral health diagnoses that are untreated. Um, and the costs show up on the physical health side. So the idea that you're going to save money by just not treating, uh, you know, mental health or addiction, um, you know, I don't think is really borne out, uh, you know, by the evidence. Um, and we know that with the comorbidities, uh, of people who have, you know, untreated, uh, mental health and, uh, substance use disorders, um, you know, they have very high comorbidities, um, oftentimes. And so in order to actually bring those down, uh, bring those costs down, you need to be treating their, uh, behavioral health conditions. Um, and, and if I may, gentlemen on kind of your earlier question about, you know, what, uh, attorneys in particular, you know, uh, you know, can be doing, you know, I would say, uh, for payers, um, uh, whether they're, uh, whether they're the insurer themselves or whether they're just administering the benefit, um, for a self, uh, funded plan, um, they do need to realize their liability, uh, under the Federal Parity Act and under erisa, uh, if it's an ERISA plan, uh, as well as under state laws. Um, you know, I think the WIT case really showed that there you have, uh, you're subject to substantial liability if you're not following, uh, these laws. Um, a also would encourage, uh, you know, attorneys, uh, at payers, um, you know, payers really need to have robust parity compliance programs. Uh, you're never going to have kind of accidental compliance. Um, these are complex products between the physical health side and the mental health side. And it's basically impossible to be compliant with parity if you don't have a robust parity compliance program. So New York State is now requiring all plans to have robust parity compliance programs just issued, uh, final regulations at the end of last year. And I think payers should be looking at those standards, uh, and just, you know, saying, you know, we need to do this in order to make sure that we're compliant. Um, I'd also say that they should make sure they're compliant with the standards in the WIC case, um, with generally accepted standards of care. Um, United was already found viable, um, and other, uh, other plans could well be found liable, uh, if they have similar, uh, issues as, as well. Um, and, you know, ultimately it's all about, uh, you know, improving, uh, improving coverage and making sure that people have the mental health and addiction services they need so that we can help keep he healthcare costs down, you know, overall,

Speaker 1: 28:10

And we think about parody, or I do as really just being, um, are you paying for the services? But, uh, in our earlier discussions, we talked a little bit about network ad adequacy and about, um, patients, David, you mentioned that have to go out of the state. And I know I've had teams with mental health issues who required significant time, um, in inpatient care and had to go two states over before they can find it. And there's no way their family can be part of that therapy visit with them effectively. And is there more to parity, um, than just dollars?

Speaker 3: 28:50

Yes. You know, cer certainly, and, uh, um, you know, and I will say that with regard to reimbursement, um, you know, it's not, it's not only, it's not that the reimbursement has to be equal on the mental health, uh, and addiction to the, uh, to the physical health side, but it has to be set in the same manner. So, you know, for reimbursement, um, you know, if you didn't have cardiologists in your network, uh, you know, most plans would raise rates, uh, you know, to bring cardiologists in network. The same type of thing should be happening, uh, on the mental health and addiction side. Um, I don't think regulators should accept the answer that, oh, we somehow set these in the same way, but yet when there's a shortage of mental health providers and they're out of network providers who aren't in network, that we aren't raising rates like that, that doesn't strike me as very equitable and is likely a violation of Federal Parity Act. Um, but kind of broader with regard to other parity violations, you know, any managed care practice that, uh, a plan has, uh, called non quantitative treatment limitations is a term of art, uh, under the Federal Parity Act. Um, you know, any of those are subject, uh, to a federal parity, uh, you know, act, uh, compliance, uh, test, and they have to be comparable to, uh, and no more stringently applied, uh, than on the mental health and addiction side, uh, as compared to the physical health side. And that's a basic test for any managed care practice of whether or not, uh, you know, it's compliant within what they call the classification of care, um, which is, for example, in network, uh, you know, outpatient. Um, so it's, uh, you know, definitely, um, basically any type of, uh, you know, practice by plans, you know, is subject to the, the PAR act.

Speaker 2: 30:35

So we do have, uh, similar issues in Delaware, like Kentucky, when we talk about things like, uh, just really access and, and network adequacy in, in, in Delaware, we're, we're not as, uh, rural as some of the surrounding states, but, uh, lower two counties, uh, we don't see, we don't have as many practices available. And, um, so we can step in when there's an issue where a person has to go out and network, um, any regulator can step in and least try to, uh, have the insurer reimbursed at the same rate. Now, when I say try, uh, like I mentioned earlier, they typically don't want to get on a advance side. So we're, we're very successful in that regard. But I, i, if not, um, you know, we have an arbitration process in our office that has recovered just last year, just under a million dollars for consumers, uh, for, you know, for all types of insurance related issues. And, um, you know, it's much cheaper than, uh, hiring, uh, an attorney. Um, and, uh, we are consumer focused here, so that's just one of the things that we offer in Delaware that I'm sure other states do as well. But, um, you know, if there's a blessing in the skies from 2020 and the, uh, COVID 19 pandemic, that is, uh, uh, our new changes to our health telehealth, uh, telehealth and telemedicine, um, laws that we have, um, adjusted so that, uh, you know, people who didn't have a primary care physician, um, or there wasn't one in their area, or they didn't have access or their children, um, or our home because schools closed, uh, really by stepping up and, uh, making it easier for folks to, to use telehealth has had a profound impact on, uh, you know, mental health treatment, uh, even physical therapy, uh, that, uh, people can now do over the phone. And with the, the change in Delaware, was it, uh, title 18, our insurance code said that you could do it over the phone and just have the audio, well, title 24, which is pro Reg, said it had to be audio and video. Well, we knew that not everyone had high-speed internet. We knew that not everyone even has a computer or, or knows how to use a computer. Um, so this really had a, a profound impact on folks in, in our most rural counties. And, uh, we had just originally, and this was a compromise when you're dealing with the General Assembly, um, we had, uh, put these provisions in and they were supposed to sunset in July of this year. Well, now the, the next general assembly has started in January, and we're gonna make this a permanent change. So we're, we've, we've heard from the providers, um, we've recognized how it has really helped, uh, people who need it the most. And that's gonna be a permanent change here in Delaware.

Speaker 1: 33:34

I love it. We're really hoping that Kentucky is following your lead, you what you've do, what you've done, and, and I can't say this enough, has really changed the nation. Delaware has, has been a real force of you should be incredibly proud of that work, you, you and your staff. Um,

Speaker 2: 33:54

I'm proud of my staff, that's for sure. They, they do the hard work. I come up with some ideas and, and the reality is, is some of our best ideas we've stolen from other states, we're not too, we're not too proud, um, because we don't know it all. And, uh, we like to take some of the, um, the best practices from other states, and we collaborate with the N A I C and exchange those ideas. And, and once I, I get the idea and turn over to my staff, they're the, the, the real heroes in, in this process.

Speaker 1: 34:21

That's wonderful. David, um, any, I guess we're drawing close to the end of our time. Uh, what, what other thoughts, what had we not touched on that you would like to share?

Speaker 3: 34:33

You know, well, certainly I think providers have a major role to play in, in advancing policy, uh, in this area and making sure that we're, you know, advancing equity and mental health coverage. Um, and, you know, one of the things that I think, uh, you know, providers can really do, um, is one, kind of understand the basics of the Federal Parity Act and your state insurance laws. Um, and then, uh, you know, actually fight denials, uh, not accept, um, not, not accept denials or, or, you know, an approval of a lower level of care that other than what's been requested, um, and, you know, bring issues to your, uh, you know, state insurance, uh, regulator, uh, or Medicaid agency, uh, you know, is really important. Uh, I do think there are a lot of opportunities, uh, uh, this year with, uh, with particularly federally, um, with a new congress, with a new administration. And Delaware, of course, I'm sure is extremely proud of, uh, president Biden, um, that we really have opportunities to advance, uh, parity and equity, um, uh, federally in, in a, in a new, uh, robust way. Um, and certainly we're looking at, um, you know, how we can, uh, you know, better help, uh, you know, states enforce the Federal Parity Act. Um, there's also some, uh, frankly, some little known provisions that allow, uh, state and federal government plans to opt out at the Federal Parity Act. Um, uh, and we're looking to kind of end that ability. Um, it's not many plans across the country, but it's still a significant number, uh, which, which is a huge barrier for people in those plans. Um, so that's will be a priority. Um, and then I think, uh, you know, more broadly, um, you know, uh, state insurance commissioners across the country have the ability to issue fines for parody violations. Um, amazingly the Department of Labor, um, does not have the ability to issue fines for self, uh, funded plans, which is, uh, you know, a very significant portion of, of the market. Uh, so we need to give the Department of Labor, uh, you know, that authority, uh, cuz otherwise, uh, you know, they essentially have no stick, um, with which, uh, you know, to make sure that, uh, plans are compliant. But, um, you know, this is a really important year, um, you know, to move forward. And certainly the telehealth provisions are absolutely critical, uh, as well. So there's, uh, certainly a lot to do, uh, you know, relating to mental health insurance coverage and equity. Um, and it's not only just through the Federal Par Act.

Speaker 1: 37:02

Yeah, definitely. And Commissioner, any parting thoughts or, uh, advice for us all?

Speaker 2: 37:08

So we hear you and, and we recognize that your early intervention, uh, and treatment is critical for our children. And that's why in Delaware we support our school-based wellness centers. Um, you know, unfortunately cuz kids aren't in school right now, um, and we know that kids are really struggling with the fact that they're not in school and the fact that they're missing out on the interaction that they're having, um, you with people, you know, instead of doing what we're doing right now, talking face to face, but on a computer and, and, uh, you know, it's really tough for our little ones who, you know, up to age or grade three, they learn to read. And then beyond that they read to learn. And it's really tough for, for our, our youngest population to, to deal with what we're all dealing as adults with, with the pandemic. So, uh, we're really, uh, concerned about that. And, um, you know, so when people actually take the step to recognize they need help and then ask for help, and then, uh, the stigma associated with that, we're, we're making strides to get beyond that. But when they turn and they have problems with, uh, their insurance covering it or, uh, covering it, but then denying ever a certain period of time, I mean, really, uh, it's counterproductive. And, um, that's something that has been a focus on our administration and in moving forward in, in 2021, we'll continue with our examinations and will continue to, uh, hold insurance companies accountable, uh, for complying with our parity laws here in the state of Delaware.

Speaker 1: 38:42

Wonderful. Well, and I will put in a closing plug for anyone, particularly attorneys and compliance officers who are interested in behavioral health. A h l a's Behavioral Health Task force brings together smart or at least talkative minds across the nation from big firms, small firms, in-house payers, and we talk about exciting issues like parody. As a group, we talk about what we should advocate, um, in front of state and federal legislators and what we can do to improve behavioral healthcare nationwide. So, uh, anyone listening to us, reach out to a H L A and, uh, please join our behavioral health taskforce. And I hope, uh, both of you guys will look us up and, and see if anything we're doing is interesting to you. So thank you very much for sharing your day with us and your insights with us. I'm very, very grateful for all you do and have learned.

Speaker 2: 39:40

Thank you. The opportunity. Yeah. Thank you so much. Appreciate it.