Children and adults with mental illness or substance use disorders face seemingly insurmountable barriers to treatment. This past July, in the shadow of the passage of federal healthcare reform legislation, regulations under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 went into effect for insurance plans that start or renew after July 1st. If appropriately implemented and enforced, these laws could deliver the most far reaching consumer protections ever enacted, and crush barriers to mental health and substance use disorder treatment.
Providers and consumers in need of care are frustrated with insurance company tactics of administrative overload, visit limitations, second guessing provider recommendations, and limited access to a very limited number of participating providers. The MHPAEA and federal regulations address these frustrations head-on by addressing quantitative limitations like numbers of visits and co-insurance amounts and non-quantitative limitations. The federal rule addresses quantitative limitations, in part, by:
· Placing restrictions on like visit limits. For the first time, insurers won’t be able to limit the number of visits an individual makes to a mental health provider unless the insurer also limits the number of visits to medical/surgical providers.
· Prohibiting insurers from charging consumers higher co-pays or co-insurance to see mental health providers than medical/surgical providers.
· Prohibiting insurers from imposing separate deductibles for mental health and substance use treatment that obstructs access to care. The regulations require that insurers have a single deductible for all services.
But what really makes the MHPAEA and its regulations revolutionary are their restrictions on so-called “non-quantitative limitations” that most severely impede access to medically necessary mental health and substance abuse treatment, and are most responsible for provider and patient angst. Non-quantitative restrictions include: prior authorization or determinations of experimental/investigational status; prescription drug formulary design; provider network admission standards, including reimbursement rates; plan methods for setting usual, customary and reasonable reimbursement rates; step therapy protocols; and, exclusions of coverage for failure to complete a course of treatment.
Imagine having to get permission from your insurance company every time you needed to see your primary care physician (PCP). We would never tolerate such a requirement on our physical health, yet it’s common practice for insurers, after a number of “pass through” visits, to impose prior authorization requirements on mental health and substance use visits. In other words, for each visit, the provider has to justify why an individual needs that visit or additional visits. Prior authorization and other medical management tools can serve a purpose, but they have been used repeatedly by insurers to restrict mental health access. The MHPAEA regulations make it a violation to make it harder to see a mental health professional than a medical provider through the use of non-quantitative limitations such as prior authorization. If an insurer elects to use prior authorization, from now on, it will have to do it in a way that is no more stringent than for medical visits.
The single biggest problem facing children and adults who need mental health or substance use treatment is the lack of participating providers or providers who will accept patients in insurance networks. The MHPAEA regulations directly address the issue of unfair or unreasonable reimbursement, the main complaint of licensed mental health professionals. Examples in the MHPAEA regulations highlight how insurers using different reimbursement methods in paying medical providers and mental health or substance abuse providers could violate the MHPAEA. Now that the MHPAEA provides a pathway to improving access to providers, providers must take up the issue and fight for parity under the new MHPAEA’s regulations.
Though the MHPAEA has been overshadowed by the passage of federal healthcare reform, the MHPAEA is major healthcare reform in its own right. The promise of mental health and substance use disorder parity is within reach for the first time in our lifetimes. The MHPAEA and its accompanying regulations provide us an extraordinary opportunity to prevent more stories of kids and adults who have to wade through a fragmented mental health and substance use disorder treatment system. Advocates, consumers, providers, and insurers all have to work to ensure that the ambitious but realistic goals of the MHPAEA become a reality.
Consumers and providers need to know their rights, and regulators need to enforce them.
Vicki Veltri is the general counsel for the Office of the State Healthcare Advocate