What Does the Parity Law Mean for You and Your Patients?

As you all know, when the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equality Act became law in October 2008, it was a major victory, gained after years of lobbying by APA and other mental health advocacy groups. The central provision of the law is the requirement that when mental health and substance use benefits are offered as part of a health plan, they must be offered with no greater financial requirements or treatment limitations than those that are applied to the plans' medical/surgical benefits for both in-network and out-of-network care. Although the law has no requirement that mental health or substance use benefits be provided, most health plans already include either one or both of these benefits, and the parity law's importance in assuring that these benefits are provided in a nondiscriminatory fashion imbue it with landmark status. The Affordable Care Act (ACA), which was passed last year, will extend the reach of the parity law's requirements.

Although the parity law went into effect on January 1, 2010, enforcement was delayed until 2011. I am writing about it now because it is critical that we all understand what this law should mean for our patients and our practices and so that we can assist our patients in ensuring that their health plans are in compliance.

The regulations governing the parity law are groundbreaking because they define not only quantitative limitations to care, but also nonquantitative limitations. These are limitations that cannot be quantified numerically such as the number of days allowed for inpatient treatment, but also benefits that limit the scope or duration of benefits when compared with other medical or surgical benefits. While the quantitative limitations include such issues as copays for in-network and out-of-network care and limitations on the number of visits permitted, nonquantitative limitations are less straightforward and include concepts such as medical management standards that are used to limit or exclude benefits based on medical necessity or whether a treatment is experimental or investigative. Other examples of non-quantitiative issues include the methodologies used to determine usual, customary, and reasonable charges; the standards used to establish provider eligibility for network participation; and the imposition of step-therapy, or fail-first protocols, that demand that a lower-cost therapy must be proved ineffective before a higher-cost one may be prescribed.

The parity law has not only the capacity to improve patient access to psychiatric care, but also the potential to improve psychiatric practice management. APA recently sent a letter to the insurance commissioner of each state to clarify that the terms of the parity law require that psychiatrists be reimbursed for providing the medical evaluation and management services for which other physicians are paid. For health plans to limit payment for care by psychiatrists to the CPT procedural codes in the psychiatry section of CPT is to limit psychiatric patients' access to care that is medically necessary. This has been an issue for psychiatry for many years. I am pleased to report that progress was made recently in New York state when, at the behest of the New York State Psychiatric Association, the Health Bureau of the New York Insurance Department sent a circular letter to all insurers in the state reminding them they are not permitted to discriminate against psychiatrists in this way (Psychiatric News, February 4). With the regulatory weight of the parity law behind us, we may be successful in ending this type of discrimination in every state.

Since the parity law's passage, APA's Office of Healthcare Systems and Financing has been critically instrumental in the effort to ensure that the law will be administered in a manner that best serves psychiatrists and their patients. In 2009, APA was a leader in the creation of the Parity Implementation Coalition (PIC), which provided a legal analysis of the parity law and its regulations. In addition to APA, the PIC includes the American Academy of Child and Adolescent Psychiatry, American Society of Addiction Medicine, Betty Ford Center, Cumberland Heights, Faces and Voices of Recovery, Hazelden, Mental Health America, National Alliance on Mental Illness, National Association of Psychiatric Health Systems, National Council for Community Behavioral Healthcare, and the Watershed Addiction Treatment Programs. The coalition is now engaged in a variety of parity compliance and enforcement activities.

Please take the opportunity to educate yourself about the parity law and contact APA with any questions that you may have. The Office of Healthcare Systems and Financing manages the PIC's parity Web site, <www.mentalhealthparitywatch.org>. It contains all the information available about the parity law, as well as information on how to get in touch with APA to report problems with any health plans whose policies seem to be out of compliance with the law, so that any infractions can be communicated to the Department of Labor for enforcement. You can contact APA's Office of Healthcare Systems and Financing directly by contacting the Practice Management Help Line at (800) 343-4671 or hsf{at}psych.org.