Enforcing Mental Health Parity
Nearly all insured Americans are now entitled to receive their mental health and substance use benefits at the same level as their benefits for other medical care.
What’s the Issue?
Traditionally, insurance providers and employers have covered treatment for mental health and substance use conditions differently than treatment for other medical conditions. Coverage for mental health care and substance use disorders had its own (usually higher) cost-sharing structure, more restrictive limits on the number of inpatient days and outpatient visits allowed, separate annual and lifetime caps on coverage, and different prior authorization requirements than coverage for other medical care. Altogether, these coverage rules made mental health and substance use benefits substantially less generous than benefits for other health conditions.
Over the past decade, Congress has enacted several laws to end this inequity. As a result, nearly all insured Americans are now entitled to receive their mental health and substance use benefits at the same level as their benefits for other medical care. Enforcing those rights, however, has not been consistent, and many patients are left to fend for themselves. The following brief provides an update to a previously published brief on Mental Health Parity, now with a focus on enforcement.
While it is fairly easy to determine whether or not plans are in compliance with quantifiable treatment limitations such as copayments, outpatient visits, or inpatient days, it is much harder to determine whether plans are using nonquantifiable treatment limitations to avoid compliance with the MHPAEA. Violations of the law regarding such limitations are likely to require more investigation than simply reviewing plan documents.
Public comments on the proposed regulations implementing the MHPAEA in Medicaid were due in June. As the single largest payer for mental health services, HHS is under pressure from advocates to quickly finalize the regulations and extend parity protections to millions of beneficiaries covered by Medicaid.
It remains to be seen whether states and the federal government are able to take on this level of effort. With states and HHS still busy with ACA implementation and enforcement activities, it is likely that we will see more cases going to court to enforce patients’ rights under the MHPAEA, especially if courts continue to give standing to advocacy or member organizations and grant class-action status.