Making Parity a Reality Requires Ongoing Advocacy, Vigilance

The Mental Health Parity and Addiction Equity Act (MHPAEA) is a landmark law and among APA’s most significant advocacy achievements.Signed into law in 2008 by President George W. Bush, MHPAEA seeks to make coverage for mental and substance use disorder (SUD) services equitable with coverage for other medical conditions. It also outlaws certain insurance practices, such as more restrictive numerical limits on inpatient days and outpatient visits as well as discriminatory copays and coinsurance rates for mental health and SUD services.

The law extends to “non-quantitative treatment limitations” (NQTLs) involving insurers’ managed care practices, such as prior authorization requirements. The law forbids plans from applying such NQTLs if they are not also applied—or as stringently applied—to other medical and surgical treatments.

MHPAEA has fostered access to mental health care for millions of Americans. However, insurance companies that do not comply with the law diminish that access, so ongoing vigilance and advocacy are necessary on the part of APA and its members.

More than 10 years after MHPAEA’s passage, many insurers remain out of full compliance with the law, particularly with regard to NQTLs. A lack of oversight from state regulatory authorities and transparency by insurers allowed insurers to design their managed care practices in a manner that imposes unequal barriers for patients who seek to use mental health and SUD services compared with those seeking other medical care. For instance, a 2018 report by the Kennedy Forum titled “Evaluating State Mental Health and Addiction Parity Statutes: A Technical Report” found that “[m]ost states have not enacted strong state parity statutes, which would ensure that state regulators have a full set of tools to make parity a reality, in large part by holding both health plan executives and state officials accountable.”

Moreover, the way that many insurers design their mental health and SUD provider networks is often not comparable with how they do so for other medical providers. For example, some health plans employ narrow or “phantom” mental health/SUD networks, whereby lists include providers who may not be accepting new patients; may have moved out of the geographic area; or, in some cases, are deceased. And some insurers categorically exclude certain medically necessary and clinically appropriate mental or SUD treatments from coverage in a manner that is not comparable to such decisions for other medical conditions.

One example of such practices was highlighted in 2018 when Aetna, one of the nation’s largest health insurers, agreed to a settlement with the Massachusetts Office of the Attorney General (AG) requiring the company to comply with state and federal laws by maintaining accurate, updated provider directories and network adequacy. The legal action brought by Massachusetts AG Maura Healey alleged that the health insurer violated state law because of inaccurate and deceptive provider directories and inadequate provider networks. The legal action also alleged that Aetna violated state law by unfairly denying or impeding member coverage for SUD treatments.

And earlier this year, the Pennsylvania Department of Insurance fined Aetna $190,000 for policies that the department says violate the federal mental health parity law, especially regarding coverage of autism and SUDs.

One result of these practices is that patients are far more likely to use out-of-network psychiatric care, leading to higher out-of-pocket costs for treatment. An analysis by Milliman Inc., commissioned by The Bowman Family Foundation, found that patients’ use of out-of-network services is much higher for behavioral health services compared with general medical and surgical services.

On average, 18.7% of behavioral health office visits were accessed out of network in 2015, while just 3.7% of primary care and medical/surgical office visits were accessed out of network. Out-of-network use of behavioral health inpatient care, compared with that of general medical and surgical care, was approximately 800% higher in California, New York, and Rhode Island and over 1,000% higher in Connecticut, Florida, New Hampshire, New Jersey, and Pennsylvania.

“The data show a persistent gap in access for patients with mental illness or substance use disorders, and we know that barriers to accessing care lead to poorer outcomes,” said Patrick Runnels, M.D., chair of APA’s Council on Advocacy and Government Relations.

Delayed or foregone treatment can have serious consequences for patients. The National Institute of Mental Health (NIMH) estimates that 46.6 million Americans were diagnosed with a mental illness in 2017, and of these, 11.2 million were living with a serious mental illness.

In that same year, an estimated 10.6 million adults had thoughts of suicide, and an estimated 47,000 completed suicide. Annual deaths from opioid overdoses reached 70,000 in 2017.

Delayed or foregone treatment also poses high downstream costs to the overall health care system—more than $100 billion per year, according to NIMH. APA is engaging in a campaign with state legislatures to further empower state regulatory authorities to combat these disparities. As a result, versions of APA’s model legislation have passed in several states (Psychiatric News).

“Through hard advocacy, APA successfully facilitated the introduction of federal parity [compliance] legislation (HR 3165/S 1737) that complements its state advocacy efforts by requiring insurers to ‘show their work’ in certifying their compliance with the [2008] federal parity law,” Runnels told Psychiatric News. “The bill requires insurers to conduct and produce comparative analyses to show that they are, in fact, complying with the federal parity law and providing required access to mental health and substance use coverage.”

APA also requested in February and in June that the Senate Health, Education, Labor, and Pensions (HELP) Committee include S 1737 in a broader bipartisan package of legislation intended to lower the cost of health care. The latest version of the Committee’s bill (S 1895, the Lower Health Care Costs Act) includes APA-endorsed parity language. On June 26, HELP approved the bill by an overwhelmingly bipartisan vote of 20-3.

APA needs the help of its members. “We urge all members to reach out to their congressional representatives and urge them to support the Mental Health Parity Compliance Act,” Runnels said. “If your state is interested in pursuing APA state model legislation, reach out to APA State Government Relations to learn more.” ■