Mental Health Parity and Addiction Equality

Mental Health Parity and Addiction Equity Act

Suicide is the second leading cause of death among people aged 10-34 in the US.  On average, 1 in 4 adults and 1 in 5 children face a mental health condition at some time in their lives.  Prisons and jails have become a “treatment center” for many and homelessness is at epidemic proportions. Few will argue against the need for a new path forward to help solve the mental health crisis we face across the country.  We must place the same spotlight and urgency on mental health and substance use as we do for other public health crises. It is time to remove the roadblocks that exist and permanently end the separate and unequal system-of-care that currently exists.

The Mental Health Parity and Addiction Equity Act (MHPAEA – Federal Parity Law) requires that insurance plans provide equal coverage of care to help address our national mental health crises.  Some shocking statistics were found by the actuarial firm Milliman showing the large out-of-network utilization disparities for mental health & addiction versus medical & surgical care for inpatient, outpatient and office visits.

Milliman’s recent report In 2017, 17.2% of behavioral office visits were to an out-of-network provider compared to 3.2% for primary care providers and 4.3% for medical/surgical specialists.  The 2017 out-of-network utilization rate for behavioral health residential treatment facilities was over 50%. Average in-network reimbursement rates for behavioral health office visits are lower than for medical/surgical office visits (each as a percentage of Medicare-allowed amounts), and this disparity has increased between 2015 and 2017.  Primary care reimbursements were 23.8% higher than behavioral reimbursements, which is an increase from 20.9% higher in 2015.

Individuals continue to pay more out-of-pocket for mental health & addiction care

Even with the MHPAEA (Final Regulation), individuals continue to pay more out-of-pocket for mental health & addiction care; and the trend is going in the wrong direction. The regulation clarifies that plans cannot discriminate in provider reimbursement rates as a way of discouraging mental health providers from participating in their network. It was determined that imposing separate deductibles for medical versus mental health would force people who needed both types of services to satisfy a higher deductible than people needing only medical services, thus creating a barrier to access benefits. Finally, to improve transparency, issuers are required to disclose medical necessity criteria used, as well as reason for a denial upon request. 

Plans can subclassify tiered provider networks and outpatient benefits (office visits versus other outpatient visits) as-long-as they are applied consistently.  Insurance plans are prohibited from imposing a financial requirement or treatment limit restriction that is more restrictive than the predominant (more than 1/2), for substantially all (defined as 2/3) medical/surgical benefits in the same classification.  The MPHEA determines equivalence by dividing benefits into six classifications:

  • in-network inpatient
  • out-of-network inpatient
  • in-network outpatient
  • out-of-network outpatient
  • emergency care
  • prescription drugs

The Department of Health and Human Services (HHS) published the ASPE study of large employers’ compliance with MHPAEA report which found employer and group health plans made substantial changes to their benefits as a result of MHPAEA and although by and large in compliance, plans routinely used stricter non-quantifiable treatment limitations (NQTLs).  The report clarified that both were subject to parity. Examples of NQTLs include:

  • pre-certification requirements
  • medical necessity criteria
  • routine retrospective review
  • medical management standards
  • prescription drug formulary design
  • standards for provider admission to networks
  • determination of provider reimbursement rates
  • requirements for step therapy (for example, using lower-cost treatments first before trying others)
  • requirements to complete a course of treatment as a condition of benefits

Access to quality care, effective screening, and community support are needed; and with the proper tools and attention, people can move on to recovery and lead productive and meaningful lives.  We need advocates such as families, schools, providers, and policymakers to unite in support of change and we must hold insurance companies accountable when examples of parity and equity do not align with standard medical and surgery benefits. 

Learn about more mental health billing codes