1. Parity: Benefit plans for the treatment of mental/psychiatric and addictive disorders, in both the public and private sectors, shall be comprehensive; i.e., they shall cover the entire continuum of clinically effective and appropriate services provided by all competent licensed professionals, and should provide identical coverage and funding to those benefits covering physical illness, with the same provisions, lifetime benefits, and catastrophic coverage.
2. Choice: Consumers shall have access to services and a choice of providers within a full continuum of network based services, including recovery and peer support programs. Network providers are to be accountable to payers and consumers by documenting the positive clinical outcomes and consumer satisfaction that they deliver. It is recognized that consumers may be required to contribute to the cost of greater choice of providers under the terms of their insurance plan.
3. Confidentiality: Consumers shall be guaranteed the confidentiality of their relationship with their behavioral health professional except when law dictates otherwise to assure their safety or the safety of others. The exchange of information between treating professionals and managed care organizations for third party clinical review for clinical effectiveness, authorization of payment, and care coordination for the purpose of improving the quality and efficiency of healthcare delivery shall be held in the strictest confidence.
4. Determination of Treatment: Decisions regarding behavioral health treatment shall be made by the duly certified and/or licensed behavioral health professionals in conjunction with the patient or his/her family as appropriate. Organizations providing Care Review/Care Authorization function as clinical consultants to the professional/patient relationship, and they authorize payment according to established criteria available to providers and consumers.
5. Review: Consumers shall be assured that any review for clinical appropriateness of their behavioral health treatment shall be done by a duly certified and/or licensed behavioral health professional.
6. Right to Know: Upon purchase of health coverage, consumers shall be informed in language they can comprehend, of the extent of their behavioral health benefits and of the appeal and grievance processes available to them.
7. Benefit Usage: Consumers shall be entitled to use all the behavioral health benefits they have purchased if the health plan's processes, including patient decision, the duly certified and/or licensed treating behavioral health professional's judgment, and the care authorization staff determine that such services are clinically effective and appropriate.
8. Compliance With State Statutes: Consumers shall not be denied treatment for services allowed under state law when those services are deemed to be clinically effective and appropriate by the health plan.
9. Disclosure: Consumers shall be informed by the licensed and/or certified behavioral health care professional providing their treatment of any arrangements, restrictions, and/or covenants established between the insurers and professionals that may influence treatment, at no jeopardy to the consumer.
10. Discrimination: Consumers who have undergone behavioral health treatment shall not be discriminated against by health, disability, life, or other insurance entities.
11. Appeals: Consumers will be given the opportunity for fair, reasonable, timely, and disclosed appeals and grievances.
12. Accountability: Providers and health plans shall be held accountable for the quality of services delivered. All parties treating or managing benefits for the patient ÷ providers, managed care entities, and health plans ÷ shall be held accountable for any injury caused by negligence in their respective services. Providers and managed care entities are responsible for implementing a health plan's benefit structure.

    AMBHA 1997 Members:
    CMG Health, Inc., Owings Mills, MD; CNR Health, Inc., Milwaukee, WI; ComCare, Phoenix, AZ; Comprehensive Behavioral Care, Tampa, FL; CORPHEALTH, Fort Worth, TX; FPM Behavioral Health, Winter Park, FL; Green Spring Health Services, Columbia, MD; Human Affairs International, Salt Lake City, UT; Managed Care Washington, Seattle, WA; MCC Behavioral Care, Eden Prairie, MN; Options Healthcare, Inc., Norfolk, VA; PacifiCare Behavioral Health, Laguna Hills, CA; PLAN 21, Houston, TX; Principal Behavioral Health Care, Inc., Rockville, MD; United Behavioral Health, Minnetonka, MN; Value Behavioral Health, Falls Church, VA; Vista Behavioral Health Plans, San Diego, CA.

    ?Further Information:
    E. Clarke Ross, D.P.A.,
    Executive Director, AMBHA
    January 1997

     

    January 1998 Additions
    (And Responses To Legislative Proposals)

13. Continuity of Care: AMBHA endorses the concept that consumers who are undergoing a course of treatment for a chronic or disabling condition at the time they involuntarily change health plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their specialty providers for up to 60 days if such services are clinically indicated. Providers who continue to treat such patients must accept the plan's rates as payment in full, provide all necessary information to the plan for quality assurance purposes, promptly transfer all medical records with patient authorizations, and abide by the health plan's authorization and other rules. [This language is similar to that proposed by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.]
14. Timelines for Authorization for Reimbursement of Care: AMBHA acknowledges that this is an important concern of consumers and we further acknowledge that the existing Medicare law provision, expanded to all health plans, has been endorsed for other health plans by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Any standardized timelines should be operationally reasonable and consistent with good clinical care.
15. Enrollee Right To Appeal Denials Through an External and Independent Peer Review Entity: AMBHA acknowledges that this is an important concern of consumers and we further acknowledge that the existing Medicare law provision, expanded to all health plans, has been endorsed for other health plans by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Such peer review entities, similar to the Medicare PRO mechanisms, should be entirely financed by agencies of the government. Such mechanism should only be used after consumers have exhausted all internal processes which should operate in a timely fashion. Such appeal does not apply for services specifically excluded from the consumer's coverage as established by contract. Review decisions shall only be made by impartial professionals with appropriate expertise in the field of health which necessitates treatment. These external review processes, if designed properly, may provide a further assurance to patients that decisions made about their health care coverage are fair and being made based on scientific evidence and best practices.
16. Non-Formulary Alternatives: AMBHA agrees that health plans with restrictive formularies should provide exceptions when non-formulary alternatives are medically necessary.
17. Consumer Access to External Ombudsman Programs: AMBHA supports consumer access to external ombudsman programs which are to be entirely financed by agencies of the government.
18. Consumer Access to External Legal Advocacy Programs: AMBHA supports consumer access to external legal advocacy programs which are to be entirely financed by agencies of the government.
19. Mandatory Choice of Health Plans: AMBHA endorses the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry recommendation that "Public and private group purchasers should, wherever feasible, offer consumers a choice of high-quality health insurance products." Further, as the 1997 Budget Act Medicaid amendments specify, in the case of an individual residing in a rural area, there should, at minimum, be a choice of at least two providers. Feasibility involves such factors as economies-of-scale, cost-effectiveness, and fiscal capacity.
20. Public Disclosure of Medical-Loss Ratio: As the medical-loss ratio only measures the expenditure of funds, differs significantly depending upon health plan structure and purchaser, and has no relationship to measuring the quality of care provided, AMBHA supports public disclosure of other components of health plan activities that document quality and focus on nationally standardized performance measures
21. Liability of Health Plan Management Agents: Consistent with AMBHA's philosophy of accountability (point #12), health plans, their management agents, and their providers must be liable for their obligations as specified in their contracts with purchasers. Enforcement of contractual obligations, nationally standardized performance measures on quality, consumer/enrollee information, and consumer appeals and grievances, including external peer review, external ombudsman programs, and external legal advocacy programs are important. This enforcement of accountability as specified in each contract eliminates the need to amend ERISA and open the floodgates of litigation. Needless and costly litigation will only increase healthcare costs.
22. Mandatory Point-of-Service: Purchasers should decide if they are going to offer a POS option, and if so, under what conditions. It is legitimate to establish financial incentives to stay within a provider network and it is legitimate to expect greater consumer out-of-pocket obligations when going outside a provider network. It is clinically beneficial for consumers to stay in networks where performance measures are expected; where providers are credentialed; and where continuity-of-care, integration-of-care, and ease of communication are enhanced.
23. Provider Privileges: AMBHA opposes governmental regulation to protect the privileges of providers. These include opposition to:
    1. Any-Willing-Provider Mandates (refer to AMBHA's January 1997 policy statement on this issue).
    2. Mandates that only the attending physician may determine hospital length of stay. Given the history of excessive and inappropriate hospitalizations, health plans must have the ability to locate, refer, and use home and community-based alternatives. Using up a capitated payment on hospitalization will prevent such alternatives. Physicians make admitting and discharge decisions but share with the health plan decisions about medically necessary length of stay.
    3. Mandates for the exact health care profession to be the peer reviewer. With over 600,000 mental health professionals in the nation such a requirement would be an administrative and financial nightmare.

AMBHA 1998 Members:
American Psych Systems, Bethesda, MD; CNR Health, Inc., Milwaukee, WI; CORPHEALTH, Fort Worth, TX; FPM Behavioral Health, Winter Park, FL; Green Spring Health Services, Columbia, MD; Human Affairs International, Salt Lake City, UT; Managed Care Washington, Seattle, WA; Merit Behavioral Care, Park Ridge, NJ; Options Healthcare, Inc., Norfolk, VA; PacifiCare Behavioral Health, Laguna Hills, CA; PLAN 21 ^*, Houston, TX; Value Behavioral Health, Falls Church, VA.

?Further Information
E. Clarke Ross, D.P.A.,
Executive Director, AMBHA
January 1998