Much was made this past week about the Obama administration’s publication of the final rules that put into place the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Some media reports are suggesting that this will take down all barriers to mental health treatment.
However, the reality is a little bit more complicated, as I last noted in this article.
The release of the final rules will have little impact to most Americans, because most insurance companies already were complying with the interim final rules. But you wouldn’t know that from the media coverage, which glossed over this, umm, important point.
Mental health parity regulations cover about 76 million working Americans, but 24.2 million Americans — about 24 percent — won’t be affected by them because of exemptions written into the law. So while it’s great to herald the final rules passage, a huge chunk of Americans won’t be eligible for its protections or benefits.
Most large insurance plans already comply with the interim final rules that had been previously published, meaning the final rules will result in very few changes for most people. As the final rules themselves note:
Analysis of a separate set of large employer-based plans for 2011 found virtually all 230 large employer-based plans included had inpatient benefits that conformed to MHPAEA standards. […]
Among the representative sample of plans for 2010 included in this study, more than 30 percent had copayments or coinsurance rates for outpatient mental health and substance use disorder benefits that were inconsistent with MHPAEA. In a separate sample of large employer-based plans for 2011, the use of higher coinsurance for mental health and substance use disorder benefits dropped dramatically. However, the study found that about 20 percent of the 140 plans tested continued to utilize outpatient in-network co-pays that failed to meet MHPAEA standards. (Page 66)
So the vast majority of plans are already in compliance with mental health parity regulations. The new rules may require some tweaks to the existing plans, but that’s about it for how it may impact you directly.
Which means this account, over at NPR by Julie Rovner and Audie Cornish, isn’t quite capturing the fact that these rules are more of a technicality than resulting in real changes (which have already been made):
That’s because once the Mental Health Parity and Addiction Equity Act barred insurance companies from imposing limits on the number of hospital days or copayments, insurance companies started looking for other ways to limit mental health and substance abuse care, like requiring preauthorizations that they don’t demand for other medical care. That won’t be allowed anymore. These rules also clarify coverage for rehabilitation or other intermediate types of care that don’t fall neatly into inpatient or outpatient categories.
It’s true — insurance companies don’t require pre-authorization for standard levels of mental health care any longer. But most haven’t had this requirement for at least a year, and some even longer. Seeing the writing on the wall with the mental health parity act, most large insurance companies actually updated their rules covering mental health treatment in the past few years.
However, that doesn’t mean insurance companies haven’t found other ways to ration mental health care, or discourage its “over-use.” What insurance companies still do legally to put limits on mental health care include:
- Require treatment update “letters” from mental health providers when they hit certain session limits.
Insurance companies argue that this is similar to what they require for physical rehabilitation — you can’t get unlimited treatments. So after 10 or 12 psychotherapy sessions, the insurance company will require the therapist to write the insurance company a letter asking for another 10 or 12 sessions for you.
If they don’t jump through this hoop, the insurance company will decline payment for those additional therapy sessions. This isn’t a “pre-authorization” since you’ve already been receiving treatment; this is just letting the insurance company know you want more. This appears to still be legal, as long as the insurance company has a similar requirement for medical benefits (like physical therapy).
- Limit their provider network in any given geographical area.
Since insurance companies already do this for medical specialties — and parity simply means equality with medical care coverage — the new rules do nothing to address this concern. Want to limit the amount of mental health treatment your coverage offers? Simply don’t provide enough mental health professionals in your network to actually cover everyone who wants treatment. That way if a new person says, “Hey, I want treatment,” the insurance company can safely say, “Sure, we have treatment. The only available therapist in our network open to new patients is only 47 miles away.”
Nothing in the parity rules address this, as long as the insurance company has similar availability (or lack thereof) for other medical specialties.
- Still needs to be a scientifically-validated treatment.
If the plan has a committee that evaluates the scientific merit of medical treatments, then mental health treatments will be held to the same standard. That means experimental and not-yet-scientifically validated treatments won’t be available to patients.
Remember, all that mental health parity means is that it needs to be largely equal to medical or surgical benefits an insurance plan offers. If an insurance company has limits on medical treatments, they can extend those same limits to mental health treatments and be within the law.
We hope the final rules help more Americans access mental health treatment. But we also recognize these rules are no silver bullet for helping all Americans gain ready access to needed mental health care or psychiatric services when they need them.
For further information
Mental Health Parity – U.S. Dept. of Labor
Affordable Care Act Implementation FAQs – Set 7
FAQs About Affordable Care Act Implementation Part V and Mental Health Parity Implementation
NPR: White House Releases Long-Awaited Rules On Mental Health
5 comments
Am I the only provider in this entire country who sees the writing on the wall what PPACA will do with mental health care when it settles in?
Psychiatrists will almost NEVER be the first prescriber for psychiatric meds on an outpatient basis, therapy will be only provided by the least qualified “therapists” as cheap is the primary drive for who is available for patients, and not only will therapy visits still be restricted, but so will access as PPACA will dictate the standards of care, and that will be putting people on medication first for any illness defined by the DSM5
Frankly, what is becoming more disturbing is not this pathetic and harmful law, but that some many people just reflexively agree to these bureaucratic standards without any dissent nor challenge.
And people wonder why repeats of Nazi Germany, Stalin Russia, and Castro Cuba will continue to happen for decades to come. Autonomy, independence, and civil disobedience are dead terms. Entitlement, dependence, and rote obedience to access trivial pleasures are the standards of human existence in most cultures these days.
And I will bet over 40% of people reading that last sentence have no clue what I mean by it!
We get the electorate we deserve.
In a Washington Post article entitled “Insurers directed to treat mental health issues the same as physical ailments, “the authors state: “But some mental health advocates said it fell short in at least one respect: It did not indicate that the rules apply to people in private health plans administered through Medicaid, the state-federal program for the poor.”
John, what does this mean? Do the parity rules NOT apply to managed Medicaid plans?
That’s correct, as far as my understanding of the final rules are. Parity does not apply to Medicaid or Medicare programs.
Gee, exceptions that governments both state and federal run.
And the Democrats want single payor health care at the end of the day.
What is that supporting via my perspective versus the disingenuous dialogue by PPACA supporters?
Hi John:
I agree with your assertion that this does not change much because most plan are in compliance anyway. We deal with one local MCO that handles a lot of business here in Alabama on cost plus Blue Cross groups. I filed a complaint with the DOL early last year and they finally said a couple of months ago there was nothing they could do under the current regulations. What they did to avoid the law was “say” they no longer required pre-authorization. They “request” the provider get visits authorized beforehand, but they say it is not “required”. If the provider does not get the visits authed they deny all claims for medical necessity and request medical records. Most providers who deal with this MCO (many will not) get the pre-auths because they are going to have to jump through the hoops on the back end anyway if they do not. Obviously, medical necessity is a requirement under both the medical plan as well as the the behavioral health plan. It was our assertion in the complaint that the Med Nec criteria were applied totally differently for medical office visits (medical records requested in maybe 5% of cases) and behavioral health visits where unless a “voluntary” auth was obtained they would be requested 100% of the time. In our opinion they had set-up a defacto authorization process. The DOL said they could not rule under the interim regs. The final regs do sort of address medical necessity, but still don’t directly address this issue as far as I can see. If the MCO refused to change their stance as of 7/1/14 do you think under the new regs our complaint would have a chance? I can send you the complaint if you would like. I appreciate your thoughts on this very much…