Access to behavioral health care is improving, but more work is needed

“The landscape for access to mental health and substance use services has markedly improve in recent years” and “it is highly likely that these trends will continue,” according to the Final Report of the White House Mental Health and Substance Use Disorder Parity Task Force. President Obama created the Task Force with the goal of developing a set of tools, guidelines, and mechanism to ensure that mental health parity is actually enforced. The Task Force’s Final Report summarizes its work including reviewing progress to date, identifying and taking immediate steps as needed, and outlining recommendations.

Task Force participants and directives

The President directed the Task Force, which included the White House Domestic Council, the Departments of Treasury, Defense, Justice, Labor, HHS, and Veteran’s Affairs as well as the Offices of Personnel Management and National Drug Control Policy, to review parity implementation; increase awareness of the protections that parity provides; and improve understanding of the requirements of parity and its protections among key stakeholders, including consumers, providers, employers, insurance issuers, and state regulations. The task force also was directed to increase the transparency of the compliance process and the support, resources, and tools available to ensure that coverage is in compliance with party and improve the monitoring and enforcement process.

Gathering information

Among the information gathered from March through October 2016, the Task Force looked at barriers to implementation and enforcement, party compliance and documenting parity violations, identifying behavioral workforce issues, documenting treatment limitations, and clarifying the role of states and the federal government in bringing about parity.

The role of mental health laws

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (P.L. 110-343) generally prohibits employment-based group health plans and health insurance issuers that provide group health coverage for mental health and substance use disorders from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. This includes restrictions related to financial requirements and quantitative treatment limitations, and nonquantitative treatment limitations. It also expands mental health parity requirements to substance use disorders, such imposing less favorable lifetime or annual dollar amount limits than the lifetime and annual dollar amount limits imposed on medical and surgical benefits.

The Patient Protection and Affordable Care Act (ACA) (P.L. 110-148) prohibits group health coverage and nongrandfathered individual market insurance from imposing lifetime and annual dollar limits on Essential Health Benefits (EHB), including mental health and substance use disorder services, and prohibits grandfathered individual markets from imposing lifetime dollar limits. The ACA increased access to mental health and substance abuse disorder coverage and parity by requiring coverage offered through Health Insurance Marketplaces and nongrandfathered health plans to cover EHBs including mental health and substance use disorder benefits. The ACA extended the application of the MHPAEA to the individual insurance market and qualified health plans and expanded Medicaid requirements to be in compliance with mental health parity.

Task Force actions

As directed by President Obama, the Task Force identified immediate actions that it could take in three main areas: education and awareness, clarification of parity requirements, and improving compliance, monitoring, and enforcement. In June 2016, the HHS and the Department of Labor jointly released a pamphlet for consumers that outlines the basic protections guaranteed by the MHPAEA and consumer rights to transparency and appeals, entitled, “Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits.” In March 2016, CMS published a Final rule to align the mental health and substance use disorder coverage benefits offered by managed care organizations, Medicaid, and the Children’s Health Insurance Program (CHIP) with parity protections required of the commercial market as well as releasing Frequently asked questions and hosting a webinar to explain the parity protections in the Final Rule.

In August of 2016, Substance Abuse and Mental Health Services Administration (SAMHSA) issued a report outlining promising best practices from state insurance commissioners related to implementing MHPAEA and monitoring and enforcement efforts to ensure compliance.

Recommendations

The Task Force recommendation fall into three main areas: supporting consumers, improving parity implementation, and enhancing parity compliance and enforcement. The Final Report identifies the specific recommendations for each area and provides details for developing and implementing the recommendations, and includes the initial steps it has taken. The recommendations include:

  • Supporting Consumers: Create a one-stop consumer web portal to help consumers navigate parity and provide simplified disclosure tools to provide consistent information for consumers, plans, and issuers.
  • Improving Parity Implementation: Update guidance to address the applicability of parity to opioid use disorder services, implement the Medicaid and CHIP parity final rule in a timely manner, conduct a thorough review of how parity principles apply in Medicare, and expand access to mental health and substance use disorder services in TRICARE.
  • Compliance and Enforcement: Provide federal support for state efforts to enforce parity through trainings, resources, and new implementation tools, increase federal agencies’ capacity to audit health plans for parity, allow the Department of Labor to assess civil money penalties for party violations, ensure parity compliance in state essential health benefit benchmark plans, and review substance use disorder benefits in the Federal Employees Health Benefits Program.

States’ failure to include substance abuse benefits goes untreated

Over two-thirds of state benchmark health plans violate requirements to cover treatment for addiction disorders put into place by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The National Center on Addiction and Substance Abuse (the Center) surveyed addiction treatment benefits offered among 2017 Essential Health Benefits (EHB) benchmark plans and found none offered what it considers to be “adequate” addiction treatment benefits. The main problem, the Center believes, is that although the ACA requires coverage of substance use disorder (SUD) services as an EHB and requires that the SUD benefits be provided at parity with comparable medical/surgical benefits, the ACA does not specifically define what those benefits should be. It leaves that up to the states, and that is where they fall short.

Analysis

The Center analyzed those benefits offered within each of the 50 states to determine the minimum level of benefits available to those covered in state exchange plans. Each state’s 2017 EHB-benchmark plan was then reviewed to determine whether it: (1) satisfies the ACA’s requirements regarding coverage of addiction benefits; (2) complies with parity requirements; (3) provides adequate care for addiction by covering the full range of critical benefits without imposing harmful treatment limitations; and (4) provides enough information to fully evaluate compliance and adequacy of benefits. Clouding the review, the Center noted, is the problem that plan documents for 88 percent of state plans lacked sufficient detail for it to fully evaluate parity, compliance, and the adequacy of addiction benefits.

Most commonly missing

Many plans either frequently exclude or do not explicitly cover benefits related to residential treatment and the use of methadone maintenance therapy. The Center found that 18 percent of the plans lacked compliance with parity requirements, while 31 percent of the plans contained possible parity violations. Over half of plans violate the EHB requirement for tobacco cessation coverage and nearly half violate the ACA’s requirement for coverage of prescription drugs to treat addiction. Although the ACA specifically prohibits the use of per-beneficiary annual or lifetime dollar limits for EHB, Texas and Michigan are in violation of this requirement. Further, Alaska’s plan does not even cover services and supplies relating to diagnosis and treatment of addiction.

“Addiction is a chronic disease that often goes untreated, and when patients can’t access addiction treatment it can lead to disability and premature death,” said the report. “In order to fulfill the ACA’s intent of dramatically expanding access to addiction treatment, states should revise their EHB benchmark plans to comply with the law … This will help to close the addiction treatment gap, improve the health of patients seeking addiction treatment, and decrease costs for the health plans in the long-term.”