President Obama formed a task force among multiple government agencies last spring to address parity for mental health insurance coverage as it relates to coverage for medical/surgical care. Agency representatives heard from payers, consumers, providers, employers, advocates and others to further define parity and how it plays out in real life. The U.S. Department of Health and Human Services issued the report in late October. Though mental health parity has been federal law for almost a decade, the law’s interpretation and implementation have been elusive. But one driver of this year’s urgency is the opioid addiction crisis that has been a hot topic in Congress in recent months. The crisis could place great demands for treatment on the system.
The report highlights the following points.
Reimbursement and Transparency
- Provider access and network adequacy is a common obstacle to treatment and this is due in part to workforce shortages in behavioral health. Some providers said a lack of parity in reimbursement for mental health providers creates a reluctance to join provider panels.
- While some of the obvious disparities in coverage like equal copays have largely been addressed, a critical enforcement issue has been in the area of Non-Quantitative Treatment Limits (NQTLs). These NQTLs are medical management requirements, which accounted for 59 percent of the U.S. Department of Labor parity violations between 2010 and 2015. Examples included disparities in preauthorization requirements, requests for written treatment plans, prescription formularies and step therapy (requiring “failure” at one level of care before gaining approval for a higher level of care). All of this stems from lingering stigma against mental health diseases and the fact that one-size-fits-all treatment approaches don’t work well for the uniquenesses of individual patient situations. It is therefore difficult for insurers to predict risk and cost in behavioral health. Lawsuits have demonstrated that their management of these services is often overly strict. Parity efforts are intended to change that.
- The report calls for greater transparency by payers in explaining criteria for restricting or denying mental health treatment.
- A patchwork of government agencies previously administered the federal parity law; three agencies will have oversight going forward – the departments of Labor, Treasury; and Health and Human Services.
- There are many variations in how parity rules apply, depending on plan size, its status as public or private and whether or not a plan is self-insured.
State Progress and Initiatives
- Some $9.3 million in grants have been earmarked to support parity enforcement at the state level. State regulators voiced a desire for training and guidance from federal agencies.
- The report recommended that the U.S. Department of Labor have authority to assess penalties for violations, a power that would require new action from Congress.
- The report mentioned promising parity enforcement practices already in place in California, Connecticut, Maryland, Massachusetts, New York, Oregon and Rhode Island.
Mental health advocacy groups praised the report, but said a proactive approach in insurance design would be more effective than relying on consumer complaints to trigger regulatory review.
With possible new demand for mental health and substance use treatment, mental health providers may be busier than ever. ABILITY supports mental health providers in many ways. Check out our Resource Center for ways to get more value out of your billing management processes.