In the past, health insurance benefits for mental health and substance use disorder treatment were far more limited than for treatment for physical health conditions. Because of these disparities, often patients did not receive the care they needed to experience recovery.
Mental health parity laws were enacted to remedy these inequities, requiring health insurers to cover mental health and substance use disorder treatment at benefit levels matching corresponding medical and surgical benefits.
The Mental Health Parity and Addiction Equity Act (MHPAEA) and its implementing regulations require parity between financial requirements (e.g., copayments, coinsurance, etc.), quantitative treatment limitations (e.g., limits on hospitalization days and outpatient visits, etc.) and nonquantitative treatment limitations (e.g., prior authorization requirements, provider networks, etc.). In addition, states have passed mental health parity laws, which must be consistent with MHPAEA, along with other legislative initiatives that promote parity such as mandated benefits and network adequacy requirements.
MHPAEA regulates health benefits for more than 170 million Americans – more than half the U.S. population – including enrollees in employer-sponsored self-insured plans, fully insured commercial health plans, and Medicaid managed care plans. (MHPAEA does not apply to Medicare.) Federal and state regulators share MHPAEA enforcement authority.
Achieving mental health parity – and the parity laws’ goal of improving access to mental health and substance use disorder treatment – has never been more critical, because our country is facing opioid and suicide epidemics. According to the Centers for Disease Control and Prevention, in 2016, there were more than 64,000 drug overdose deaths. The opioid epidemic cost the U.S. economy approximately $500 billion in 2015 alone, according to the White House Council of Economic Advisers.
Given MHPAEA’s importance, how can we assess and promote compliance? As with health insurance generally, MHPAEA is complicated. Strictly speaking, assessing MHPAEA compliance requires analysis of the terms – as written and in operation – of each health insurance plan or policy. Given that there are hundreds of health insurance companies in the U.S. offering thousands of products, this is a daunting challenge.
As a practical matter, federal and state regulators typically assess MHPAEA compliance by sampling health insurance products via market conduct exams or by investigating complaints filed by consumers and their advocates.
Another compliance challenge is that some aspects of MHPAEA are relatively straightforward, whereas others are much more nuanced. Although testing for comparability of financial requirements such as copayments requires actuarial calculations of benefits paid and involves interpretive judgments, many health insurers have performed the mathematical tests detailed in the regulations. In contrast, assessing the comparability of nonquantitative treatment limitations such as prior authorization or provider reimbursement rates is much more complex, and there is currently no consensus on the elements that must be examined.
Perhaps the most challenging aspect of assessing MHPAEA compliance is one of perspective. Many mental health and substance use disorder treatment advocates believe that MHPAEA compliance should be evaluated by outcomes such as rates of approval, denial of claims, and waiting time to see a provider. Health insurers, on the other hand, stress that MHPAEA requires parity of processes, not outcomes. How can we bridge this gap?
Harvard health economist Richard Frank – a key architect of MHPAEA’s regulations – distinguishes between parity in law (meeting the requirements of MHPAEA) and parity in principle (providing access via insurance to quality behavioral health care that is on par with access to quality medical care). To the extent that MHPAEA addresses how insurers manage health care, however, in assessing compliance it is necessary to examine both of these concepts.
Numerous peer-reviewed studies have explored the impact of MHPAEA through surveys of health plan officials, examination of plan documents, and analyses of claims data. Although these studies do not reach conclusions about compliance with the law, they provide useful insights.
These studies have explored changes in benefit structure (such as copayments or excluded benefits), service utilization, and spending on mental health and substance use disorder treatment. Generally, researchers have concluded that MHPAEA has impacted these factors to the benefit of consumers, but that more research and compliance efforts are needed regarding access to treatment, in particular through examination of nonquantitative treatment limitations. Additionally, more research is needed on the impact of MHPAEA on treatment outcomes.
As regulators, health insurers, providers, and consumer advocates attempt to assess compliance with MHPAEA through various strategies, it would be helpful to have a uniform approach to compliance testing. A detailed MHPAEA roadmap, such as one offered by an independent accrediting body, reflecting regulations and guidance, as well as the experience of regulators, health plans, providers, and consumers would benefit all stakeholders. By offering and evaluating the implementation of such a roadmap for assessing compliance, private accreditation can advance MHPAEA’s goals.