Marketplace Pulse: Differences in Cost-Sharing for Mental Health and Primary Care Services Persist

The Marketplace Pulse series provides expert insights on timely policy topics related to the health insurance marketplaces. The series, authored by RWJF Senior Policy Adviser Katherine Hempstead, analyzes changes in the individual market; shifting carrier trends; nationwide insurance data; and more to help states, researchers, and policymakers better understand the pulse of the marketplace.

Unmet demand for mental health services is a longstanding healthcare system problem that has worsened in recent years. There is an increasing awareness of insurance-related barriers such as inadequate provider networks, claims denials, and differential benefit designs that make it harder to access mental health services versus other kinds of care. These factors have led enrollees needing mental health services to go without care or use more expensive out-of-network providers.

In response, the White House recently announced a new proposed rule that would build on the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). A 2020 update to the Parity Act required insurers to analyze their coverage rules to ensure they are not more restrictive for mental health services and share those analyses with state and federal regulators when asked. The rule announced last month would strengthen these requirements by requiring plans to analyze access and make changes when differences are shown to exist. The rule also aims to clarify ambiguities so as to "make it clear what plans can and cannot do."

The new rule focuses primarily on non-quantitative limits to treatment, such as inadequate networks and prior authorizations. These limits are difficult to measure but can pose significant barriers to treatment. Policymakers should also take note of a more easily measured barrier that remains a problem—differential benefit designs that result in higher patient cost-sharing for mental health versus physical health services. Last year, we reported that there was a significant difference in cost-sharing in individual market plans. In particular, we found that silver plans were about 50% more likely to require that the deductible be satisfied before a mental health visit than in the case of a primary care visit.

A re-examination of this issue in 2023 shows that the situation remains unchanged. At each metal level, plans are more likely to require that the deductible be met before cost-sharing for a mental health visit as compared to a primary care visit. For silver plans, which are the most popular, the difference is the greatest. Of the nearly 4,000 silver plans offered in 2023, nearly two-thirds (63%) did not subject either mental health or primary care services to the deductible. Approximately 20% of plans subjected both types of services to the deductible. The remainder, approximately 17% of silver plans, required that the deductible be satisfied for mental health visits but not PCP visits.

Texas has the largest number of these plans, with Colorado, Illinois, Georgia, and Florida also well represented. About 40% of silver plans that subject mental health but not PCP visits to the deductible are offered by Elevance, Cigna, or United Health. Most of the rest are offered by state Blue plans.¹ Since the average cost of a mental health visit is approximately $90, subjecting these services to the deductible is a significant barrier to access, since many mental health conditions require repeated visits.

Plans that treated mental health and primary care services equivalently from the perspective of the deductible were also likely to use similar payment types (copay versus coinsurance) and similar payment amounts for the two types of services. For example, for plans that do not subject either mental health or primary care services to the deductible, the great majority require a copay, and the differences in the average copay amount for mental health and primary care is not significant, with a median of about $35 for both services.

While there has been a sustained trend toward increasing the share of services that are not subject to the deductible, the gap between mental health and primary care has not narrowed, and in fact it widened in the most recent year. These cost-sharing differences are not necessarily a violation of the mental health parity law, since parity is currently required to exist between mental health and most medical/surgical services.

As part of the effort to provide more clarity about “what plans can and cannot do,” the new rule might note definitively that cost-sharing for a behavioral health visit cannot exceed that for other types of primary care visits. Increasingly, behavioral health is seen as an essential part of high-quality primary care, which is defined as integrated care of the “whole person.” Yet given that the majority of PCPs are not equipped to provide most behavioral health services, behavioral health may be a type of primary care that cannot always provided by traditional primary care providers. Classifying mental health as a specialty for the purpose of cost-sharing makes it more difficult for many people to receive the “whole-person” care that they need.

¹ CSR plans excluded from the analysis. Cost-sharing differences are much smaller in the Small Group market. Data from Ideon.