Insurers Found to Be Complying With Certain Parts of Parity Law

The mental health parity law appears to have been effective at eliminating quantitative treatment limits (QTLs) for large insurance plans, according to a study published December 15 in Psychiatric Services in Advance.

Before the Mental Health Parity and Addiction Equity Act (MHPAEA) went into effect in 2010, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such QTLs were allowed only if they were “at parity” with medical-surgical limits. A study of claims processed by Optum, a large managed behavioral health organization, found significant differences after the law went into effect, reported Amber Thalmayer, Ph.D., and colleagues. At the time of the study, Thalmayer was affiliated with Optum; she is now at the Institute of Psychology, University of Lausanne in Lausanne, Switzerland.

Between 66 percent and 90 percent of plans in 2008-2009 had annual limits on inpatient or outpatient services, with medians of 30 days and 45 visits, said Thalmayer and colleagues. By 2011, fewer than 1 percent of carveout plans and 3 percent of carve-in plans still had limits on those services.

The researchers speculated that the potential administrative burden of matching mental health coverage with other types of medical/surgical coverage made it simpler to eliminate the treatment limits.

“The passage of MHPAEA, the most far-reaching and comprehensive parity law to date, had substantial impacts on QTL use among managed behavioral health organizations (MBHOs),” they wrote. “Before MHPAEA, most carve-in and carveout plans in our sample limited behavioral health visits, regardless of a member’s diagnosis. In 2010, most QTLs were dropped, and by 2011, virtually all plans had dropped QTLs on behavioral health care. Plans with limits postparity presumably include a mix of plans with analogous medical limits and plans that had not yet complied.”

Perhaps most important was the benefit to patients with serious mental illness who would incur high out-of-pocket expenses without the protection of the parity law. “One of the most meaningful impacts of MHPAEA is improved insurance protection for needed specialty behavioral health care for children and adults with depression, bipolar disorder, or psychosis, who were most likely to reach their inpatient and outpatient limit thresholds preparity,” the researchers wrote.

Irvin “Sam” Muszynski, APA’s senior policy advisor and director of parity enforcement and implementation, said the study documents the success of the parity law. “This is good news,” he said. “It should not be a surprise since the plans are now prohibited from applying quantitative treatment limits unless they establish similar QTLs for medical/surgical.”

More problematic has been enforcement around restrictions on non-quantitative treatment limits (NQTLs). These include managed care and utilization review practices that a plan may use to substantially limit treatment services.

A final rule issued by the Centers for Medicare and Medicaid Services in 2013 offered an expansive interpretation of the parity law, saying health plans could not apply NQTLs on mental health and substance use disorder treatment that are not also applied to general medical care. For instance, the final rule confirmed that provider reimbursement rates might constitute a form of an NQTL that is prohibited by the final rule; that is, plans and issuers can look at an array of factors in determining provider payment rates such as service type, geographic market, demand for services, supply of providers, provider practice size, Medicare rates, training, experience, and licensure of providers, but the rule reconfirms that these factors must be applied comparably and no more stringently than on providers of mental health/substance use treatment.

Moreover, under the final rule, parity requirements for NQTLs are expanded to include restrictions on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services (including access to intermediate levels of care). The net effect of this is that plans cannot require patients to go to a facility for mental health/substance use treatment in their own state if the plan allows its members to go out of state for other medical services (Psychiatric News, December 6, 2013).

One especially acute problem has been “network adequacy”—health plans whose network of mental health providers is inadequate to meet the demands for care; this requires patients to seek out-of-network services or to forego care altogether. In some cases, this problem has involved deceptive advertising; plans may advertise networks that include providers who are no longer seeing new patients, have moved out of the geographical area, or are deceased.

A 2016 survey by researchers from the APA Foundation found that a majority of network psychiatrists listed as practicing in the Washington, D.C., area by three major health plans in the District of Columbia health exchange are either not able to schedule an appointment or not reachable at the telephone numbers listed for enrollees to call (Psychiatric News, June 10, 2016).

“In many respects NQTLs are the new QTLs,” Muszynski said. “The White House Task Force on Parity acknowledged this, and CMS has given grants to 20 states to increase efforts around compliance with the MHPAEA.” ■