U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

A. In 1999, the President directed the Office of Personnel Management (OPM) to equalize benefits coverage in the year 2001 for mental health and substance abuse conditions with benefits coverage for other illnesses or diseases in the Federal Employees Health Benefits (FEHB) Program.

National research organizations, advocacy groups, and agencies charged with the oversight of government health programs tell us that there is a growing consensus on the effectiveness of treatment and the ability of managed health care delivery systems to control costs. Most experts agree that mental health and substance abuse diagnoses have well-established biological bases, diagnoses are reliable, and treatment is effective and available. Research has convinced us that the FEHB Program can expand mental health and substance abuse benefits cost effectively. We believe that this is important because adequate mental health and substance abuse benefits coverage has been shown to improve patient health, provide patients with greater financial protection against unforeseen costs, and to reduce work place absences and employee disabilities.

A. Parity in the FEHB Program means that benefits coverage for plan mental health, substance abuse, medical, surgical, and hospital providers will have the same limitations and cost-sharing such as deductibles, coinsurance, and copays. Historically, health plans have applied higher patient cost-sharing and shorter day and visit limits to mental health and substance abuse services than they did to services for physical illness, injury, or disease. Beginning January 1, 2001, this practice stopped when patients use plan providers and follow a treatment regime approved by their plan.

A. Since 1990, about three-fifths of the States have passed laws that require the same or similar levels of coverage for mental and physical illnesses. A study by the Substance Abuse and Mental Health Services Administration found that State parity laws have had a small effect on premiums due primarily to the ability of managed behavioral health care organizations to control costs.

Recent advancements in the treatment and management of mental illness have left no justifiable rational for disparate treatment of mental illness. The National Institutes of Mental Health informed us that most mental health diagnoses have well-established biological bases, diagnoses are reliable, and treatment is effective, available, and affordable.

A. That appears to be a myth. A growing body of research and actual industry experiences indicate that parity can be implemented without substantially increasing premiums, as long as it is coupled with efforts to manage the benefit. These studies have been highlighted in several recent reports to Congressional committees.

A study by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that new actuarial estimates of full parity implementation across all product types project an average 3.6 percent premium increase. The National Advisory Mental Health Council estimates cost increases of between 1 and 3 percent.

A number of private sector companies are already providing parity, and it’s costing about 25 cents a day, at the most. That’s much less than some people predicted. For the FEHB Program the cost will be even less.

The average increase for fee-for-service plans is 1.64%, for HMOs its .30%, with an aggregate Program increase of 1.3%. Per biweekly pay period, those with a self-only enrollment will pay $0.46 for parity. Family enrollees will pay $1.02.

A. When patients use plan providers and follow a treatment regime approved by their plan, all diagnostic categories of mental health and substance abuse conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) will be covered.

A. We believe that to actually end discriminatory treatment of coverage for mental illness, we must provide coverage for all diagnoses of mental illness. All services that are medically necessary to diagnose and treat a mental illness should be covered to the same extent that coverage is provided for a physical illness or disease, or we really haven’t achieved equality of coverage. Restricting parity to specific diagnoses perpetuates disparate treatment.

A. We have encouraged health plans to manage mental health and substance abuse care in order to expand your coverage cost effectively while maintaining quality service. The goal of managing care is to only authorize appropriate and cost-effective treatment. This process can include directing you to a specific provider, requiring you to get prior authorization from the plan for non-emergency services, and requiring you to follow a treatment regime authorized by the plan. The authorization process may require you to call a phone number so the health plan can assess your needs and refer you to an appropriate provider to treat your condition.

Some health plans will manage your care through managed behavioral health care organizations (MBHO) and their networks of providers, while others will manage it through their own provider networks and internal processes. The health plan or its MBHO will typically review your provider’s prescribed services to make sure that they follow standard practice and are appropriate for your condition.

A. A managed behavioral health care organization is a company that contracts with health plans to provide a range of behavioral health services to the plan’s enrollees. MBHOs specialize in managing care in the mental health and substance abuse fields so they are uniquely equipped to help you receive the best care available for your condition. MBHOs manage your care by only authorizing appropriate and effective treatment.

A. That depends on the health plan that you select as to whether or not you have coverage for providers who are not in the health plan’s network. The FEHB Program offers a variety of health plan types including fee-for-service plans, preferred provider organizations, health maintenance organizations, and point-of-service options. All fee-for-service plans, preferred provider organizations, and some point-of-service options offer coverage for providers outside the health plan’s network for mental health and substance abuse services. Health maintenance organizations usually limit benefits coverage to providers participating in their networks. Please check your health plan’s benefit brochure to see if it provides coverage for providers outside of its network.

Remember, if your health plan provides coverage outside of its network, your out-of-pocket costs for these services will be significantly greater than if you use providers in your health plan’s network. Also, keep in mind that certain services may only be covered when you receive them from providers in your health plan’s network. Check with your health plan for coverage details.

A. Federal agency personnel, particularly Employee Assistance Program (EAP) staff, represent an important front line in our effort to do this. In a memo to Directors of Personnel, we offered information and assistance to them and their EAPs, enlisted their support, and encouraged their suggestions.

Since front line EAP personnel are involved in the initial assessment of conditions and treatment referrals, they play a vital role in achieving healthy outcomes for Federal employees and their families. To ensure that EAP personnel can effectively coordinate the changes that will occur at the beginning of 2001, we have already held several meetings, and have scheduled a half-day conference on October 16 to bring EAP and health plan personnel together to meet and share information. We expect that this will bring everyone up to date on health plans’ benefits, network entry procedures, authorization processes, care transition procedures, and telephone systems to facilitate appropriate referrals.

A. In most cases your health plan, or your health plan’s MBHO, will have a phone number for you to call so that they can assess your needs and refer you to a provider qualified to treat your condition. If you need help in contacting your health plan while at work, your employing agency Employee Assistance Program personnel can assist you.

In a non-emergency situation you must follow the health plan’s authorization process to qualify for parity benefits. If you are experiencing an emergency (e.g., symptoms should be sever enough to make you believe that the absence of immediate treatment would place your health in serious jeopardy) seek help immediately. Then, as soon as reasonably possible contact or have your provider, family member, or friend contact the health plan so that your care can be coordinated. Check your specific health plan’s emergency benefits requirements since certain limitations could apply.