At long last, the Administration has released the final
rule implementing the Mental Health Parity and Addiction Equity Act of 2008.
This will extend mental health insurance benefits on a par
with medical/surgical benefits to at least 30 million more people.
And, more importantly, we have finally ushered in a 21st
Century response to a set of diseases for which we still often employ 19th
Century treatments – locking the door and throwing away the key.
The Mental Health
Parity Act (MHPA) was passed in 2008.
Its purpose was to end insurance discrimination against people with
mental illness.
For larger group health plans, it outlawed annual and
lifetime limits on mental health or substance use disorder benefits when there
are no annual or lifetime limits on medical/surgical benefits. And it required
that co-insurance and co-payments be substantially the same for both mental
health and regular medical/surgical procedures.
As it turned out, the MHPA needed the Affordable Care Act
(ACA) for it to work most effectively. And vice-versa.
ACA extended MHPA protections to the small group and
individual markets, and made mental health and substance use disorder benefits
“essential benefits” that all marketplace insurers (i.e., non-grandfathered
plans) had to cover.
But ACA also relied on state benchmark plans to determine
how the essential mental health benefits were defined. This opened the door to the possibility that
a state might use its own definition of parity – one less strict that the
federal government’s – in defining those benefits, even though the MHPA set a
standard federal approach.
For years, we have wondered how the final rule would
reconcile the two laws.
Good news – the final
rule makes the uniform, minimum parity standard come to life.
According to the final rule, states can require better
parity coverage than is required by the federal law.
But they cannot set minimum levels of coverage that are less
than those demanded by the MHPA. And if
there is a dispute about this, the rule’s preamble clearly spells out how such
a dispute should be resolved: “An insurer subject to MHPAEA may be required to
provide mental health or substance use disorder benefits beyond the state law
minimum in order to comply with MHPAEA.” (p. 46)
Still, there are
limitations to the law and the rule.
For one thing, the MHPA does not by itself mandate that all
insurance products include behavioral health coverage – we need ACA for this. As
the rule notes, while treatment limitations are not permitted under the MHPA, “a
permanent exclusion of all benefits for a particular condition or disorder… is
not a treatment limitation for purposes of this definition.” (Sec. 54-9812-1, p.103)
Also, it does not establish uniform co-pays for
providers. The co-pay for a behavioral
health provider’s service may still be different from, say, the co-pay for a
primary care provider’s service. Instead,
the co-pays are calculated based on the co-pays set for all similar medical/surgical
services covered in the plan.
And in high-deductible plans certain prevention services,
such as screening, may be covered at no cost, while other mental health
services may either have a cost or not be covered at all (see the preamble, p.
18-19).
Finally, the rule does not entirely resolve the question of
provider rate-setting – a post-MHPA
issue that arose in Florida when one insurer singled out mental health
providers and reduced their rates in late 2011: “Plans and issuers may
consider a wide array of factors in determining provider reimbursement rates
for both medical/surgical services and mental health and substance use disorder
services.… The NQTL provisions require that these or other factors be applied
comparably to and no more stringently than those applied with respect to
medical/surgical procedures…. The Departments may provide additional guidance
if questions persist with respect to provider reimbursement rates.” (p. 24)
But all in all, this
is a good rule.
It extends the parity provisions that have covered most of
the 130 million people in large groups under the interim rule to an additional
30 million people (p. 64), and does so at an affordable price.
This expanded coverage will cost an estimated $10.55 per
person initially, and up to $1.13 billion over five years (p. 78). It will result in an insurance premium
increase of less than 1 percent in both the individual and small group markets.
The new rule will cover all plans issued, or renewed, after
July 1, 2014. That will be a good day
for fairness and equity.
Note: I started writing Our Health Policy Matters exactly three years ago, in November, 2010. Since then, I've published at least one new column per week, without a break. So, for the first time, I'll be taking a couple of weeks off. I will not publish next Wednesday or the week after, but will return with new columns after Thanksgiving. If there is breaking news between now and then (and no, I don't consider the low Obamacare enrollment numbers to be newsworthy right now, but about what should have been expected based on the enrollment numbers for the now-put-to-bed PCIP program!), I may publish something off-schedule, and catch you up after vacation if you don't visit the site between now and then. In the meantime, if you enjoy OHPM, I encourage you to take a look at some of the older columns you might not have had time to read in the past. And feel free to contact me directly with ideas you may have for future columns! And thanks for reading - I've been averaging 13,000 readers per month lately. Not huge by some Web standards, but not too bad either for a once-a-week health policy effort. I thank you, and wish you a very Happy Thanksgiving!
Paul Gionfriddo via email: gionfriddopaul@gmail.com. Twitter: @pgionfriddo. Facebook: www.facebook.com/paul.gionfriddo. LinkedIn: www.linkedin.com/in/paulgionfriddo/
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