While mental health parity in insurance coverage has been a right “on paper” for years, many mental health advocates say that laws designed to ensure equal coverage for treatment of mental illness and substance use are not being enforced, in part because how parity is defined isn’t particularly clear. But mental health providers are poised to have more detail than ever before.
Clarification is coming in part from settled lawsuits. New York and California are the most aggressive states in enforcing mental health parity and litigation there has determined that factors such as availability of residential treatment, stringency of utilization review, rate of treatment denials, range of diagnoses covered, adequacy of networks and formulary design are all relevant criteria for comparing mental health and medical coverage.
Elsewhere, parity is often still expressed as comparable copays for office visits and other obvious markers of cost, while utilization review and the use of “medical necessity” criteria still cloud and discourage access to services. According to a recent article by the Pew Charitable Trusts, patients often don’t realize they are entitled to see the medical necessity and decision criteria that affect the authorization of their care.
Insurers say they have worked with regulators to interpret government rules, which began as a sweeping mandate, but initially offered little in the way of specifics. Health plans have supported more recent parity legislation and offer examples of creative health plan case studies demonstrating proactive outreach, integration and coordination of care.
Mental health providers will have much more to work with when a presidential task force report on parity best practices is issued Oct. 31, 2016. Check back for follow-up coverage on this subject.