Evidence record
CMS Did Not Ensure That Selected States Complied With Medicaid Managed Care Mental Health and Substance Use Disorder Parity Requirements
- Publication date
- March 2024
- Source record
- Original document linked
Findings
6
Recommendations
8
Overall conclusion
CMS did not ensure that selected States complied with Medicaid managed care MH/SUD parity requirements; noncompliance was widespread across eight States, including missing parity provisions in contracts, lack of parity analyses and public posting, and restrictive practices by MCOs on MH/SUD benefits. CMS concurred with the recommendations and outlined actions to strengthen oversight and guidance.
Scope
Audit assessed CMS oversight of MH/SUD parity compliance in Medicaid managed care across eight states (Arizona, New Jersey, New York, Texas, Illinois, Kansas, Mississippi, and South Carolina) with Medicaid managed care contracts in effect on or after October 2, 2017. The objective was to determine whether CMS ensured that selected States complied with Medicaid managed care MH/SUD parity requirements, including whether state contracts with Medicaid Managed Care Organizations (MCOs) contained MH/SUD parity provisions by the compliance date (October 2, 2017), whether parity analyses were conducted and posted to the public by the compliance date, and whether MH/SUD benefits were delivered in parity. The parity analyses cover four benefit classifications (inpatient, outpatient, prescription drugs, and emergency care) and test five elements: (1) aggregate lifetime and annual dollar limits; (2) financial requirements (coinsurance, deductibles, copayments, and out-of-pocket maximums); (3) quantitative treatment limitations (QTLs); (4) nonquantitative treatment limitations (NQTLs); and (5) availability of information related to medical necessity and denial reasons. CMS oversight included review of state and/or MCO parity analyses, contract provisions, and the posting of compliance information on state Medicaid websites. Fieldwork occurred August 2022 through October 2023, with reference to the compliance date and historical parity activities dating back to 2017; extensions were granted in certain cases, and data from 2017–2023 were analyzed to assess ongoing compliance.
Findings (6)
Each finding has a stable link.
- F-253
CMS did not ensure that selected States complied with Medicaid managed care MH/SUD parity requirements. For all eight States reviewed, State contracts with Medicaid MCOs did not contain required parity provisions by the compliance date (October 2, 2017).
- F-254
Five States did not conduct required parity analyses across their delivery systems, and eight States did not make parity compliance information available to the public by the compliance date.
- F-255
States and their MCOs may not have delivered MH/SUD services in parity; MCOs applied financial requirements that were more restrictive for MH/SUD benefits than medical/surgical benefits in two States, and imposed quantitative treatment limits (QTLs) that were more restrictive in six States; all eight had nonquantitative treatment limitations (NQTLs) that were not comparable or were more stringent than for medical/surgical benefits.
- F-256
Noncompliance issues identified in specific states persisted as of the end of fieldwork (e.g., Illinois, Kansas, New York, South Carolina).
- F-257
Noncompliance details included that NQTLs were present in all eight States and varied across other categories (e.g., prior authorizations, formulary design, etc.).
- F-258
Some parity analyses were conducted and posted after the compliance date, but in several cases, posting occurred late or not at all by the date.
Recommendations (8)
- R-259
Modify State policies and procedures to require written procedures for reviewing MCOs' compliance with MH/SUD parity requirements and ensure ongoing monitoring.
Related finding F-254 - R-260
Require States to require MCOs to update parity analyses when benefits change or deficiencies are corrected; require newly added MCOs to conduct parity analyses; conduct timely follow-up with MCOs.
Related finding F-254 - R-261
Ensure States maintain documentation of CMS communications with States relating to parity requirements and corrective actions.
- R-256
Improve CMS oversight of States' compliance with MH/SUD parity requirements, including strengthening follow-up procedures to verify that parity analyses are performed across MH/SUD delivery systems.
Related finding F-253 - R-257
Require States in which MCOs conduct parity analyses to submit the information their MCOs provide regarding compliance with parity requirements to CMS during contract approval.
Related finding F-254 - R-258
Follow up with States that have identified noncompliance to verify that corrective actions have been taken and are effective; maintain documentation of communications with States.
Related finding F-256 - R-262
Require States to improve monitoring of MCOs' ongoing compliance by modifying policies and procedures to include written MH/SUD parity review processes, require updated parity analyses when benefits change, and ensure newly added MCOs conduct parity analyses.
Related finding F-254 - R-263
Require timely follow-up with MCOs that have identified noncompliance to verify corrective actions and address deficiencies.
Related finding F-256