Mental Health Parity Cost Projections and Behavioral Health Transition Plan​

Behavioral Health is Indicative of a High-performing Culture​

Behavioral health (that is, mental health and substance use disorder, collectively) is an essential aspect of both workplace compliance management and the assurance of employee wellbeing. ​

Coverage of behavioral health conditions within the scope of treatment and services available in an employer sponsored health plan is about more than simple compliance assuredness; this coverage is essential to attraction and retention of a qualified and motivated workforce, and generally indicative of a high-performing workplace culture. ​

Burn out, family and financial stressors, preexisting behavioral health conditions, and societal pressures all contribute to form a perfect storm for an employer’s workforce. ​

Absent the basic and vital behavioral health resources necessary to preempt and contain behavioral health detractors, an employer may inadvertently motivate its work force into job recirculation, financial peril, and in the worst instances, accelerate the occurrence of, or even exacerbate underlying conditions related to, behavioral health-related disorder management. ​

Substance use related costs are destroying the US

• Opioid use continues to explode
  • ​Prescription opioid abuse costs $78.5billion annually in the form of healthcare, legal programs, and lost productivity.​
• Overdose
  • Fentanyl overdose rates outpace prescription opioid overdoses by 550.94%.​
• Alcohol
  • Alcohol is the most popular drug in the U.S., with nearly half of Americans ages 12 and older saying they used it in the last month.​
  • Nearly 22% admitted they engaged in binge drinking in the past month.​
• Nearly a Quarter of the US population uses drugs
  • 59.277 million or 21.4% of people 12 and over have used illegal drugs or misused prescription drugs within the last year.​

​Workplace impacts associated with SUD

Employers are unprepared

• 75% of employers say substance use is prevalent among their employees, but only 17% feel prepared to address the issue. ​

Staggering costs of SUD

• SUD can cost as much as $81 billion in absenteeism ,presenteeism, loss productivity, higher healthcare bills, and workers’ compensation claims.​

SUD role in workplace injury

• The U.S. DOL reports that 65% of on-the-job accidents are related to drug and alcohol abuse in the workplace. ​

Workplace injuries

• Employees suffering active SUD are five times more likely to file claims for workers’ compensation for work-related injuries.​

Employees in recovery

• Miss 13.7 fewer days than workers with untreated SUD& help employers save $8,175 in replacement, healthcare, and related costs. ​

Part one: holistic compliance assuredness​

Why is Behavioral Health Management Necessary?

Consistent with the Mental Health Parity & Addiction Equity Act(“MHPAEA”), coverage of behavioral health conditions remains a largely voluntary proposition for a private employer; however, both houses of Congress, along with the most-recent four presidential administrations, have advocated for enhanced coverage of behavioral health conditions within employer-sponsored health coverage. ​

In fact, coverage of behavioral health conditions was one of the main focuses of the Patient Protection and Affordable Care Act(the “ACA’), and one of the primary reasons MHPAEA enlisted coverage of behavioral health conditions as essential health benefits and as an aspect of the concept of minimum value of employer sponsored insurance. ​

The ACA mandates that private and public employers employing fifty of greater fulltime employees and/or fifty fulltime employee equivalents(or “FTEs”), to make an offer of affordable, minimum value, minimum essential coverage to such employees. ​

In this context, the required and essential health benefits include coverage for behavioral health benefits, including substance use disorder benefits. Similarly, in this context, the concept of ACA-qualifying minimum value coverage necessarily implicates behavioral health coverage, including coverage of substance use disorders.​

The next page addresses the appropriate applications for purposes of “minimum value coverage” and “essential health benefits.”​

Essential Health Benefits 

​Mental and behavioral health services are considered deemed “essential health benefits” for purposes of the ACA. ​

Consequently, most individual and small employer health insurance plans, including all plans offered through the Health Insurance Marketplace®, must cover mental health and substance use disorder services. ​

Also required for coverage are services that can help support participants with behavioral health challenges and related disorders, such as counseling, in-patient treatment, and other interventions.​

Minimum Value Standards

The “minimum value” is a standard of minimum coverage that applies to job-based health plans. If an employer’s plan meets this standard and is considered “affordable,” employees won’t qualify for a premium tax credit if they buy a Marketplace insurance plan instead.​

A health plan meets the minimum value standard if both of the following conditions apply:​

• The coverage is designed to pay at least 60% of the total cost of medical services; and, ​
• Benefits include substantial coverage of physician and inpatient hospital services.​
  

Part two: increasing employee wellbeing & improving occupational outcomes​

Complimenting the employer’s holistic compliance assuredness agenda, coverage of behavioral health conditions and related disorders serves the essential employer goals of increasing employee wellbeing and improving occupational outcomes for the employer’s workforce. To be sure, behavioral health compliance assuredness activities and a focus on improving occupational outcomes for an employer’s workforce operate in tandem. ​

Industry experts and other thought leaders opine that for every dollar an employer spends on improvement of behavioral health outcomes, the employer realizes a ten dollar return on its investment in behavioral health improvement. ​

Cyclical termination and hiring can prove detrimental to workplace culture and productivity. However, when employees are supported across the four quadrants of employee wellbeing (physical, behavioral, financial, and family health), they endure cultural differences and workplace challenge in a more effective and resilient manner; thus, employer shave the prerogative and the incentive to assure each quadrant of employee wellbeing, to the extent they want to compete for the most qualified, capable, and competitive workforce. ​

Costs of behavioral health related compliance avoidance​

• Civil Monetary Penalties: The DOL is authorized to assess civil monetary penalties in the instance of MHPAEA compliance avoidance at the rate of $100.00 per day of noncompliance/per participant.
• ACA Related ESRP Penalties: In accordance with the ACA’s Employer Shared Responsibility Provisions, employer penalties may be assessed at the rate of $4,350.00 annually per fulltime employee in the event the minimum value standard is unsatisfied.
• Civil Litigation Costs: MHPAEA authorizes a federal private right of action in the instance of an employer’s failure to comply with the substantive provisions of the law. While it is difficult to predict total litigation costs, federal litigation is quite costly.
• Reprocessing of Claims & Notice Violations: The Department of Labor is authorized to require reprocessing of all denied behavioral health related claims and appeals, to the extent that an employer is found deficient respecting its MHPAEA compliance activities.
• ERISA Penalties: The DOL is also authorized to assess a penalty of up to $100 per day of non-compliance with the employer’s ERISA Fiduciary Duties, including production of the employer’s comparative written comparative analysis of NQTLs when requested.​

Phased behavioral health compliance Initiative

Phase I: 3 months

• Conduct Employer Education Campaign. Rollout of employer education campaign focusing on substantive compliance assuredness and the development of a holistic environment of employee wellbeing.​
• Design Drugfree Workplace Initiative. Design the elements of an employee-facing drugfree workplace campaign, scheduled for rollout during Phase II of the behavioral health initiative.

Phase II: 3 months

• Rollout Drugfree Workplace. Rollout of drugfree workforce campaign coupled with a generalized behavioral health awareness programming initiative for the employer’s workforce.​
• Health Plan Design. Design and implementation of behavioral health expansion for purposes of employer-sponsored health insurance alternatives.

Phase III: 6 months

• Implement Plan Design Modification. Amendment of plan documents and features to account for coverage of behavioral health related disorders.​
• Prepare Documents & Notices. Drafting of new plan documents and other participant disclosures, as required to account for coverage of behavioral health disorders.

Phase IV: 6 months

• Perform NQTL Analysis. Evaluation of plan design features and engagement of third-party professional services provider for production of the employer’s written comparative analysis of nonquantitative treatment limitations (“NQTLs”). ​
• Perform Participant Disclosures. Review and satisfaction of participant disclosure requirements for behavioral health related claims and appeals.

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