speaker: jane horvath september 11, 2014
DESCRIPTION
A Review of Behavioral Health Benefits in Newly Reformed Individual Marketplaces- Services and Drug Coverage Sponsored by Produced by. Section I A comparison of behavioral and physical health benefits as well as provider networks in Bronze and Silver plans in five states. Section II - PowerPoint PPT PresentationTRANSCRIPT
A Review of Behavioral Health Benefits in Newly Reformed Individual Marketplaces- Services and Drug Coverage
Sponsored by
Produced bySpeaker: JANE HORVATH
September 11, 2014
Section IA comparison of behavioral and physical health benefits as well as provider networks in Bronze and Silver plans in five states.
Section IIAn analysis of drug coverage, utilization management, and cost-sharing for 25 products in nine states.
INTRODUCTION
Mental Health America and Takeda-Lundbeck commissioned comparative research of Bronze and Silver level individual market Exchange plans in nine MHA- priority states (AZ, CA, CO, IL, MD, MT, NJ, NY, TX).
SECTION I: A comparative review of services, cost-sharing, and provider networks for behavioral and physical health in individual market Exchange plans in five of the nine priority states.
SECTION II: A market scan of plan formularies to assess coverage, tier placement, utilization management, and cost-sharing trends for 25 antidepressants and bipolar therapies in the individual market Exchange of the nine priority states.2
SEC
TIO
N I
BEHAVIORAL HEALTH BENEFITS AND PROVIDER NETWORKS
• Cost-sharing• Office visits, inpatient, outpatient?• In-network, Out-of-network?• Is BH included in OOP Maximum?
• Deductible• Separate BH?• Any services excluded?
• Access• BH provider in-network?• Prior authorization or referrals
required for access?
SECTION I:
STUDY QUESTIONS
4BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS
• Compared and contrasted the behavioral health and physical health benefits in two Silver and two Bronze metal level plans in the individual market in the Exchanges of the most populous regions of five MHA –priority states: AZ, IL, MT, NJ, TX.*
• Used publicly available documents – plan summary of benefits and coverage, plan provider search functions.
• When available, only used data on providers listed as accepting new patients but four plans (20%) did not have this public capacity
• Assumed that unless otherwise specified, an BH provider is considered a ‘specialist” in each plan and patient access requires specialist-level cost-sharing
• Selected oncologists as comparator group to psychiatrists after consultation with MHA.• There may be duplication in provider counts because some plan search functions include each provider location as a distinct, countable provider.
SECTION I:
METHODOLOGY
5
*These are all Federally-Facilitated Exchanges which keep plan information public outside of the open enrollment period. State exchanges had incomplete data available for this analysis and thus were not included in this Section.BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
Findings:BEHAVIORAL HEALTH SERVICE ATTRIBUTES
No clear distinctions in services/cost sharing between metal levels or states.
All plans appear to technically comply with the Mental Health Parity and Addiction Equity Act• All plans have equal or comparable
cost sharing and utilization management requirements for physical, mental and behavioral health.
• There were no explicit service restrictions on behavioral health services in any plan.
• Behavioral health cost sharing included in the out of pocket maximum of all plans.
Service Coverage Highlights:• 8 plans (40%) require prior
authorization or referral for specialist care
• 7 plans (35%) have no cost sharing for both inpatient in-network behavioral health and substance abuse services
BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 6
Findings:BEHAVIORAL HEALTH PROVIDER NETWORKS
This research is not sufficient to evaluate network adequacy. All these plans meet federal requirements for adequacy.
Nearly all plans included coverage for non-physician providers, such as licensed clinical social workers or licensed mental health counselors. Depending on the plan behavioral health providers may or may not include psychiatrists.
Seven plans have over 350 behavioral health providers in network, while nine plans have over 100 mental health providers in-network.
Six plans have fewer than 10 behavioral health providers in-network.
Thirteen plans (65%) have a greater number of psychiatrists than oncologists in-network.
Caveats:• All plan provider network information may not be
up to date;• Some plans do not provide information on which
providers accept new patients, and • This research does not include demographic
analysis that might better answer a question of network adequacy.
BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 7
BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS
Summary:BEHAVIORAL HEALTH PROVIDER NETWORKS
With all the caveats about data quality and sample size;
Out of pocket costs appear to be equal to physical health.• Issues
• Is there behavioral health primary care?
• Are there clinical preventive services that could be considered for first dollar coverage?
Robust networks are not a guarantee of access.• Did not study demographics of access:
time, distance, or income.
8
BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS
> MORE PSYCHIATRISTS THAN ONCOLOGISTS= BEHAVIORAL HEALTH AND PHYSICAL HEALTH COST-SHARING IS THE SAME< LESS PSYCHIATRISTS THAN ONCOLOGISTSX NO INFORMATION* THESE NUMBERS DO NOT TAKE INTO ACCOUNT PROVIDERS LISTED AT MULTIPLE LOCATIONS. MAY OR MAY NOT INCLUDE PSYCHIATRISTS.
COMPARING BEHAVIORAL AND PHYSICAL HEALTH BENEFITS AND PROVIDER NETWORKS
State Plan
Inpatient, In-Network Cost-Sharing
Behavioral Health vs. Physical Health
Outpatient, Out-of-Network Cost-Sharing Behavioral Health vs.
Physical Health
Psychiatrists vs. Oncologists
Overall Number of Behavioral Health Providers*
Arizona
Humana Connect 6300/6300 Bronze = = < 592 BCBS Everyday Health Alliance 6000 Bronze = = > 7
Humana Connect Silver = = > 589
BCBS Everyday Health Alliance 4000 Silver = = > 7
Illinois
Blue PPO Bronze 006 = = > 0
Humana Connect Bronze 6300/6300 = = > 1346
Blue Choice Silver PPO 003 = = > 0
Humana Connect Silver 4600/6300 = = < 1346
Montana
Access Care Bronze = = < 5
SmartHealth Value Bronze 3000 = = > 189 PacificSource: SmartHealth Value Silver 3000 = = > 190 Connected Care Silver: Montana Health
Cooperative = = < 4
New Jersey
AmeriHealth NJ Tier 1 Advantage – Bronze EPO = X < 22
Horizon Advantage EPO Bronze = = > 45
Horizon Advance EPO Silver = = > 45
AmeriHealth NJ Tier 1 Advantage – Silver EPO H.S.A. = X < 22
Texas
Blue Advantage Bronze HMO 005 = = > 399
Blue Advantage Bronze HMO 006 = = > 399
Molina Marketplace Silver Plan = = < 21
Blue Advantage Silver HMO 003 = = > 399
• Developed by HHS and DoL• Actual interpretation will likely
develop and be refined over time with federal guidance, lawsuits, etc.
• Only two plans in this study specified the need for a covered service to be medically necessary • Both are Illinois plans and the
service in question was primary care
MEDICAL NECESSITY DEFINITIONS
All plan summary of benefits and coverage refer to the ACA Uniform Glossary for the definition of “medical necessity”
BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS
Medical Necessity-“Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
-ACA Uniform Glossary
10
Findings: BRONZE VERSUS SILVER PLANS
From a behavioral health/substance abuse standpoint, Bronze vs. Silver AV level was not indicative of less cost sharing or a stronger provider network.
In two states, Texas and Illinois, Silver plans had higher cost sharing than Bronze plans—for both inpatient and outpatient coverage.
Five plans require no cost sharing for behavioral health/substance abuse outpatient services. • Four Bronze, one Silver.
Seven plans require no cost sharing for behavioral health/substance abuse inpatient services. • Four Bronze, three Silver.
Behavioral health provider network participation seems more highly correlated to carrier/plan sponsor than metal level.
Network participation information captured in this analysis reflects all the shortcomings of the carrier/plan public data.
BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS
11
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPY COVERAGE
SEC
TIO
N I
I
• Reviewed 25 behavioral health drug treatment therapies for coverage in plans sold on the individual market Exchanges of nine states using publicly available summaries of benefits and coverage and drug formularies.
• Plans included were selected on the basis of largest enrollment or plans in the most populous region of a state.
• Where coverage varied based on dosage form or strength, Breakaway captured information on the form/strength with the least access restrictions.
• All averages are simply mathematical averages, not weighted.
• 72 plans (36 Bronze, 36 Silver)
• 4 Bronze, 4 Silver per State
• 2 HMOs, 2 PPOs per State/per metal level where possible (EPO and POS used in absence)
ProductsAbilifyBrintellixCelexaClozarilCymbaltaEfexorFetzimaGeodonInvegaLatudaLexapro
PaxilPristiqProzacRisperdalSaphrisSavellaSeroquelViibrydZoloftZyprexa Depakote
LamictalLithaneTegetrol
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
SECTION II:METHODOLOGY
13
States ReviewedArizona CaliforniaColorado IllinoisMarylandMontanaNew JerseyNew YorkTexas
AVERAGE COVERAGE RATES WITHIN STATES
The average frequency of coverage for 25 products among 8 plans in each the 9 states.
All Exchange plans are required by law to have an appeals process to request a drug not listed on a plan’s preferred drug list.
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Arizona
Californ
ia
ColoradoIlli
nois
Montana
Maryland
New Jerse
y
New YorkTexa
s0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
87%
62% 62%
95%
84% 83%79%
75%79%
Average Coverage Rates of All 25 Behavioral Health Therapies Within Each State
14
N= 8 plans/state
Arizona California Colorado Illinois Montana Maryland New Jersey
New York Texas0%
10%20%30%40%50%60%70%80%90%
100%90%
60% 61%
93%84% 84% 82%
62%
85%84%
64% 62%
96%
84% 81%76%
88%
73%
Average Coverage Rates Across States by Metal Tier
Bronze Silver
State
Perc
ent o
f Dru
g Li
sts/
Form
ular
ies
AVERAGE COVERAGE RATES WITHIN STATESBY METAL LEVEL
15
Branded Generic0%
10%20%30%40%50%60%70%80%90%
100%
50%
6%
50%
94%
Average Coverage Rates of Branded and Generic Products
No Yes
Perc
ent o
f Dru
g Li
sts/
Form
ular
ies
AVERAGE COVERAGE RATES OF BRANDED VS. GENERIC THERAPIES
Includes all drugs in all plans across all 9 states.
16
BRANDED COVERAGE FINDINGS
9 branded productsAbilifyBrintellixFetzimaInvegaLatudaPristiq SaphrisSavellaViibryd
• All drugs covered in each Metal level by at least one plan• Illinois and Texas
• No Difference in Coverage Count Among Metal Levels• Illinois, Texas, Colorado, Montana, New
Jersey • Greater Product Coverage in Bronze v Silver
Plans• Texas, California
• Greater Product Coverage in Silver v Bronze Plans• Arizona, Maryland, New York
• No state had no coverage of brands in any metal level• Brintellix frequently excluded on one or
both levels• Pristiq only excluded in Montana
17
TIERING “CLUSTERS” BY PLAN TYPE
Count of covered products by tier across all 72 plans and across all 9 states.
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Tier 1 Tier 2 Tier 3 Tier 4 Plan Does Not Specify
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
48%
13%
23%
6%9%
63%
8%
28%
0% 1%
61%
11%
20%
6%3%
65%
9%
22%
2% 0%
Tiering Clusters of All Covered Products by Plan Type
HMO PPO EPO POS
Perc
ent o
f Dru
g Li
sts/
Form
ular
ies
18
• Drugs with high rates of coverage are placed on Tier 1•Celexa, Lithane, Risperdal, Lexapro
• Infrequently covered drugs, when covered, are commonly on Tier 3•Viibryd, Brintellix, Fetzima, Saphris
TIERING “CLUSTERS” BY METAL LEVEL
Count of covered products across all 72 plans across all 9 states
• Drugs with high rates of coverage are placed on Tier 1•Celexa, Lithane, Risperdal, Lexapro
• Infrequently covered drugs, when covered, are commonly on Tier 3•Viibryd, Brintellix, Fetzima, Saphris
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Tier 1 Tier 2 Tier 3 Tier 4 Plan Does Not Specify
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
53%
12%
23%
4% 8%
61%
9%
28%
2% 1%
Tiering Averages of All Covered Products by Metal Level
Bronze Silver
Perc
ent o
f Dru
g Lis
ts/F
orm
ular
ies
19
TIERING “CLUSTERS” BY STATE
Count of covered products across all 72 plans across all 9 states
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Tier 1 Tier 2 Tier 3 Tier 4 Plan Does Not Specify0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
53%
6%
27%
2%
12%
59%
12%
28%
1%0%
63%
27%
7%
0%1%
57%
2%
29%
1%
12%
70%
10%
19%
0% 0%
59%
11%
21%
9%
0%
77%
5%
9%
0%
9%
59%
15%
26%
0% 0%
51%
12%
23%
14%
0%
Tiering Clusters of All Covered Products By State
Arizona California Colorado Illinois Montana MarylandNew Jersey New York Texas
Tier
Perc
ent o
f Dru
g Lis
ts/F
orm
ular
ies
20
FINDINGSCOST SHARING
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
OVERVIEW OF FINDINGS
• Use of prescription-only deductibles in 4 states: AZ, CA, IL, MD• Lowest in CA ($250)• Varies significantly by metal
level
• Little variation in copays and coinsurance by metal level
• High rates of utilization management, especially quantity limits
21
AVERAGE PRESCRIPTION-ONLY DEDUCTIBLESBY STATE
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Arizona California Illinois Maryland Overall $-
$200
$400
$600
$800
$1,000
$1,200
$1,400
$730
$250
$1,167$1,000
$778
Average Rx-Only Deductible Across States
StateAv
erag
e Rx
Ded
uctib
le
• Only 4 states analyzed used a prescription-only deductible, with CA’s being significantly lower than the rest.
• The other states in the study used combined (medical+prescription) deductibles, which were not captured in this analysis.22
AVERAGE PRESCRIPTION-ONLY DEDUCTIBLESBY METAL LEVEL
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Bronze Silver Overall $-
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600 $1,500
$698 $778
Average Rx-Only Deductible by Metal Level
Metal Level
Aver
age
Rx D
educ
tible
23
• Among the 4 states using a prescription-only deductible
COST-SHARING IN PLANS WHERE RX EXEMPT FROM ANY DEDUCTIBLEBY METAL LEVEL
Average copays by metal level across all states and among all plans that exempt Rx from any deductible.
Only includes plans that specify a copay amount.
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 24
Bronze Silver $- $5
$10 $15 $20 $25 $30 $35
$28 $30
Average Copay in Plans Where Rx Exempt From Combined Deductible
Metal Level
Dol
lars
AVERAGE COST-SHARING WHEN DRUGS APPLY TO DEDUCTIBLEBY METAL LEVEL
Average cost-sharing among all plans and across all states
Only includes plans that specified a cost-sharing value greater than $0 or 0%
Top chart is average copay before any deductible is met by metal level
Lower chart is average coinsurance before any deductible is met by metal level
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 25
Bronze Silver $-
$5
$10
$15
$20
$25
$30
$35 $30
$17
Average Copay Before Deductible is Met
Metal Level
Dol
lars
Bronze Silver0%
10%20%30%40%50%60%70%80%90%
100%100% 100%
Average Coinsurance Before Deductible is Met
Metal Level
Perc
ent
AVERAGE COST-SHARING WHEN DRUGS APPLY TO DEDUCTIBLEBY METAL LEVEL
Average cost-sharing among all plans and across all states
Only includes plans that specified a cost-sharing value
Top chart is average copay after any deductible is met by metal level
Lower chart is average coinsurance after any deductible is met by metal level
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 26
Bronze Silver $- $2 $4 $6 $8
$10 $12 $14 $16 $14
$3
Average Copay After Deductible is Met
Metal Level
Dol
lars
Bronze Silver0%
10%20%30%40%50%60%70%80%90%
100%
23%11%
Average Coinsurance After Deductible is Met
Metal Level
Perc
ent
Abilify
Brintellix
Celexa
Clozaril
Cymbalt
a
Depak
oteEfe
xor
Fetzi
ma
Invega
Lamict
al
Latu
da
Lexa
pro
Lithan
ePax
il
Pristiq
Proza
c
Risperd
al
Saphris
Savell
a
Sero
quel
Tegetr
ol
Viibryd
Zeldox
Zoloft
Zyprexa
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
76%
100%
41%35%
77%
0%
31%
100%
81%
0%
81%
31%
0%
31%
81%
36%
52%
80%
57%62%
0%
81%
67%
31%
54%
Utilization Management Rate Among HMO Plans
Product
Perc
ent o
f Dru
g Lis
ts/F
orm
ular
ies
AVERAGE UTILIZATION MANAGEMENTBY PLAN TYPE
Key takeaway:
Slightly higher application of UM in HMO plans with a similar, though less frequent, pattern across drugs among PPO plans
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Branded Generic
23
Abilify
Brintellix
Celexa
Clozaril
Cymbalt
a
Depak
oteEfe
xor
Fetzi
ma
Invega
Lamict
al
Latu
da
Lexa
pro
Lithan
ePax
il
Pristiq
Proza
c
Risperd
al
Saphris
Savell
a
Sero
quel
Tegetr
ol
Viibryd
Zeldox
Zoloft
Zyprexa
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
78%
86%
21%26%
43%
4%8%
100%94%
0%
89%
13%
0%
13%
69%
8%
29%
94%
56%
29%
0%
94%
38%
4%
38%
Utilization Management Rate Among PPO Plans
Product
Perc
ent o
f Dru
g Lis
ts/F
orm
ular
ies
Branded
AVERAGE RATE OF UTILIZATION MANAGEMENT BY STATE AND TYPE OF UMKey takeaways:
Quantity limits most common UM approach
Step therapy is a significant UM approach
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES
Arizona
Californ
ia
ColoradoIlli
nois
Montana
Maryland
New Jerse
y
New YorkTexa
s0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
52%
37% 36%
50%
12%
37%
5%8%
42%
10%
16%
1%
20% 21%
3%
0%
17% 16%15%13%
1%
10%
3% 3%
18%
4%0%
Rates of Utilization Management Type of UM By State
Quantity Limits Step Therapy Prior Authorization
State
Perc
ent o
f Dru
g Li
sts/
Form
ular
ies
28
KEY FORMULARY TAKEAWAYS
Few differences in cost-sharing between Bronze and Silver plans
Branded products covered less often and placed on Tier 3 when covered
High utilization management rates, particularly for branded drugs
Quantity limits used heavily in most states
No readily available information to indicate disparate treatment of behavioural health/substance abuse services from physical health. 29
A Review of Behavioral Health Benefits in Newly Reformed Individual Marketplaces- Services and Drug Coverage
Sponsored by
Produced bySpeaker: JANE HORVATH
September 11, 2014
COVERAGE RATES OF EACH DRUG BY STATE
AP
PEN
DIX
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 32
Abilify
Brintellix
Celexa
Clozaril
Cymbalta
Depakote
Efexor
Fetzi
ma
Invega
Lamict
al
Latuda
Lexa
pro
Lithane
Paxil
Pristiq
Proza
c
Risperd
al
Saphris
Save
lla
Sero
quel
Tegetrol
Viibryd
Zeldox
Zoloft
Zypre
xa
Avera
ge0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0% 0%
100%
75%
100%
75%
100%
0% 0%
100%
0%
100%
75%
100%
50%
100%100%
0% 0%
100%
75%
0%
100%100%
75%
61%
0% 0% 0% 0% 0% 0% 0% 0%
62%
Coverage Rate Among 8 Colorado Plans by Metal Level
Bronze Silver
Product
Perc
ent o
f Dru
g Lis
ts/F
orm
ular
ies
Branded
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 33
Abilify
Brintellix
Celexa
Clozaril
Cymbalta
Depakote
Efexor
Fetzi
ma
Invega
Lamict
al
Latuda
Lexa
pro
Lithane
Paxil
Pristiq
Proza
c
Risperd
al
Saphris
Save
lla
Sero
quel
Tegetrol
Viibryd
Zeldox
Zoloft
Zypre
xa
Avera
ge0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%100%
25%
100% 100%
75%
100% 100%
25%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
93%
50%
100%
50%
96%
Coverage Rate Among 8 Illinois Plans by Metal Level
Bronze Silver
Product
Perc
ent o
f Dru
g Lis
ts/F
orm
ular
ies
Branded
FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 34
Abilify
Brintellix
Celexa
Clozaril
Cymbalta
Depakote
Efexor
Fetzi
ma
Invega
Lamict
al
Latuda
Lexa
pro
Lithane
Paxil
Pristiq
Proza
c
Risperd
al
Saphris
Save
lla
Sero
quel
Tegetrol
Viibryd
Zeldox
Zoloft
Zypre
xa
Avera
ge0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%100%
0%
100% 100%
75%
100%
0%
75%
100% 100%
0%
100% 100%
75%
100%
75%
100%
75%
100% 100% 100% 100% 100%
75%
82%
50% 50%
100%
50% 50% 50% 50%
0% 0% 0%
100%
76%
Coverage Rate Among All 8 New Jersey Plans by Metal Level
Bronze Silver
Product
Perc
ent o
f Dru
g Lis
ts/F
orm
ular
ies
Branded