An Introduction to the Mental Health Parity Act for Consumers
In this edition of our Humanizing Healthcare series, we draw attention to Mental Health and Substance Use Disorders (MH/SUD). Prior to COVID-19 you may never have paid attention to your Mental Health Benefits coverage. However, many of us have been reminded over the last few years of how important MH/SUD benefits can be to ourselves and our loved ones. Since 2020, the incidence of mental illness has skyrocketed across the United States. A study by the Kaiser Family Foundation (1), concluded that “From September 29 – October 11, 2021, 31.6% of adults in the U.S. reported symptoms of anxiety and/or depressive disorder, up from 11.0% in 2019”. The Lancet (2) published the following charts to summarize the impact of the COVID-19 pandemic on mental disorders, by age and gender:
If you work with health plans, you probably already know about Mental Health Parity (MHP) laws. If you don’t, why should you care?
First, many good people, politicians, advocates, healthcare professionals, and policy makers have been working hard for decades to ensure you and your loved ones have equal coverage for MH/SUD conditions as for medical/surgical services. But the rules are complex, and even health plan professionals struggle to maintain compliance.
Second, it is likely that you know someone – a parent, sibling, child, friend, co-worker – who is struggling with or has passed away due to a MH/SUD condition. So, understanding the MHP laws and the benefits that must be covered by your health insurance carrier puts you in a position to make a difference in someone’s life today or in the future when the need arises.
Historically, mental health services were not covered in the same way as medical/surgical services. There were no regulations mandating insurance plans to cover MH/SUD conditions. And even when such conditions were covered, they typically were subject to higher cost shares and treatment caps than medical/surgical services. The goal of mental health parity laws has been to ensure your health insurance covers mental health and substance use disorder (MH/SUD) services at the same level as medical/surgical services (parity in coverage).
On 26 September 1996, President Bill Clinton signed the Mental Health Parity Act (MHPA)(3) into law as the first step towards this goal. The MHPA required group health plans and insurance carriers offering mental health benefits to ensure annual and lifetime dollar limits on mental health services are not lower than dollar limits on medical/surgical services.
In 2008, the MHPA was superseded by “The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)”, which was signed into law by President George W. Bush. The MHPAEA expanded the MHPA and addressed the issue of parity on financial requirements such as co-pays, deductibles, and out-of-pocket maximums; treatment limits such as caps on visits, inpatient days, etc.; and nonquantitative treatment limits such as medical necessity reviews and prior authorization requirements.
Significantly, neither the MHPA or the MHPAEA required health plans to cover MH/SUD benefits. That changed for small group plans and individual health insurance coverage in 2010, when President Barack H. Obama signed the Patient Protection and Affordable Care Act (ACA). Basically, small group and individual insurance must cover “essential health benefits,” which include MH/SUD benefits. And plans that cover MH/SUD benefits also must comply with federal mental health parity rules.
While actual data is not available, we believe that with the passing of the ACA, most health insurance plans in the country now cover MH/SUD and must comply with these regulations. It is worth noting that health insurance is also regulated at the state level, and some states have even stronger mental health parity laws.
Know Your Rights to Receive Comprehensive Mental Health Coverage
So, when does one know that they are experiencing mental health problems? If you struggle with this question, you are not alone. MH/SUD conditions manifest themselves in different ways in different people. The signs and symptoms can be overshadowed by other events in our lives, so it is easy to suffer with them for months or even years without knowing. The Department of Health and Human Services has provided a list of early warning signs here https://www.mentalhealth.gov/basics/what-is-mental-health. The Mental Health Institute (https://www.nimh.nih.gov/), the lead Federal Agency of Mental Health Research, elaborates on several mental health hot topics. Please visit these sites to learn more if you are concerned about your mental wellbeing or the mental wellbeing of a loved one.
Assuming you have done some research, it is time to contact your insurance plan to get help. If your insurance covers mental health, which is the case with most plans, you should expect the same level of service you would receive if seeking medical/surgical services. If you experience challenges, it is possible that your plan is not complying with the MHPAEA. Here are some red flags to watch for:
The insurance plan directs you to call a different company or provider that is unresponsive to phone calls and/or emails. If this is happening at a level that is not acceptable for medical/surgical benefits, then it shouldn’t be acceptable for MH/SUD. The network may be inadequate.
The insurance plan tells you that there are no appointments or that you need to travel 30+ miles out of your zip code to get care. Again, not acceptable.
You are told pre-authorization is required to determine medical necessity. Ask if the criteria for determination of medical necessity are the same for MH/SUD and medical/surgical services. Using more stringent criteria for MH/SUD services than medical/surgical is not in compliance.
You are approved for care but there is a cap on the number of visits and there is no cap on medical/surgical benefits for similarly situated conditions.
Your cost shares (co-pay, deductible or coinsurance) are higher for MH/SUD services than cost shares for medical/surgical services.
Understanding your rights and asking for additional information to ensure compliance or for ways to file a formal complaint may help you get the care you deserve.
Are we there yet? In other words, are we at parity yet? The answer is simple, NO. We have made considerable strides as a nation but practically the level of attention paid to MH/SUD illnesses is still not at parity with care for medical/surgical health. Even though most insurance plans state that there is parity, the reality is access to care, quality of care, and unfortunately the stigma associated with MH/SU disorders prevents people from seeking care or getting the quality of care they need. For those who seek care, there is fear of judgement and bias from many fronts - employers, healthcare providers, family, friends, etc. This impacts access to resources and quality of care.
As we move forward, it is up to our collective efforts to educate ourselves and recognize that MH/SUD illnesses deserve the same compassion and level of care as physical health. Until then, biases and stigmas will remain a major barrier to receiving quality care.
Is recovery from MH/SUD even possible? According to MentalHealth.gov, “Most people with mental health problems can get better. Treatment and recovery are ongoing processes that happen over time. The first step is getting help.”
Where can you get help? (Ref: https://www.mentalhealth.gov/get-help/immediate-help)
For life-threatening situations, call 911, available 24 hours a day.
If you need help evaluating your health plans for compliance with MHPAEA, Athena Actuarial Consulting can help. We specialized in Mental Health Parity Financial Requirements Testing (“Substantially All” and “Predominant” Tests), Quantitative Treatment Limits (QTL) and Non-Quantitative Treatment Limits (NQTL) Assessments. Book a Meeting with Our Health Expert.
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