Mental illness affects a significant number of Americans, and many of them are not able to get the treatment they need. Even when health plans cover mental health benefits, they can be harder to access and less comprehensive than other types of health benefits.
The Mental Health Parity Act (MHPA) of 1996 was the original legislative attempt to force providers of group health insurance for employees to furnish the same levels of coverage for mental health benefits as were provided for medical / surgical (M/S) benefits.
Prior to the enactment of the MHPA, health benefit providers had been slow to recognize that mental health disorders were as important in terms of needing effective treatment as physical health conditions. Federal legislation over the years has expanded the scope of the MHPA to press health benefit providers to make mental health treatment as accessible as other health benefits.
Though improvements in access to mental health treatment are being made, parity with access to M/S benefits has not been achieved, and legislative efforts to enforce compliance by health benefit plan providers continue.
Mental Illness and Substance Use in America
According to the Substance Abuse and Mental Health Services Administration (SAMHSA) annual survey on mental illness and substance use levels, one in four adults – over 83 million Americans – had a mental illness. More than 12 million adults had serious thoughts of suicide, and 1.7 million attempted to take their lives.
Over 46 million people ages 12 and above met the criteria for having a substance use disorder, with 30 million people classified as having an alcohol use disorder and 24 million people classified as having a drug use disorder. The highest incidence of substance use disorder was among young adults ages 18 to 25.
The Mental Health Parity and Addiction Equity Act (MHPAEA)
The MHPAEA (Parity Law) was passed in 2008 and added addiction diseases to the mental health parity requirement. The Parity Law requires group health coverage providers to make financial requirements and treatment limitations no more restrictive for mental health or substance use disorders (MH / SUD) than for other medical and surgical benefits.
Out-of-pocket financial expenses to access MH / SUD benefits like co-payments, deductibles, and co-insurance must be no greater than the predominant expenses incurred to access substantially all medical / surgical benefits.
Quantitative treatment limitations on the scope or duration of treatment, such as the number or frequency of visits, are subject to the same standards as financial expenses. Non-quantitative treatment limitations (NQTL) are other criteria that are used to limit the scope or duration of treatment and have separate standards to determine parity.
NQTL can be any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH / SUD benefits. Some examples of NQTL would be using any of the following as criteria for authorizing treatment:
- Requiring prior authorization for services
- Concurrent review to determine the medical necessity of continuing services
- Standards for care providers to participate in provider networks
- Prescription formularies – drug choices based on cost
- Step therapy protocols – require fewer treatments to be tried first
What Employer Plans MHPAEA Applies To
The federal Parity Law only applies to health plans covering more than 50 employees. MHPAEA requirements do not apply to:
- Non-federal governmental plans with 50 or fewer employees
- Private employers with 50 or fewer employees
- Group health plans that incur a minimum increased cost when implementing MHPAEA standards
Health Plan Providers are not Required to Offer MH / SUD Coverage
Mental health parity only applies to health providers who choose to offer coverage for mental health disorders under MHPAEA. The Parity Law does not require that group health benefit plans provide MH / SUD coverage. It only says that if they do, the benefits must be as easily accessed as the other types of benefits offered.
The Affordable Care Act (ACA)
Effective in 2014, the ACA expanded the reach of mental health and substance use disorder parity to small group and individual health plan providers and made MH / SUD coverage mandatory as an essential health benefit under the affected plans.
The ACA requires all individual and group health benefit plan providers to offer preventative services benefits for items that have a rating of A or B from the United States Preventative Services Task Force (USPSTF).
The USPSTF A and B recommendations include screenings for anxiety disorders, depression and suicide risks, perinatal depression, and unhealthy drug or alcohol use.
The Consolidated Appropriations Act (CAA)
The CAA took effect in 2021 and further expanded the MHPAEA. It requires group health insurance providers offering both M / S and MH / SUD benefits to perform and document a comparative analysis of the design and application of NQTL used for M / S treatments, and NQTL used for MH / SUD treatments.
The analyses must be made available to the Department of Health and Human Services (HHS) upon request, and an annual report to Congress will be made public summarizing the results.
After two years of requesting and reviewing analyses from group health benefit plan providers, it was concluded in the 2023 MHPAEA Comparative Analyses Report to Congress that there is still a lot of noncompliance with parity requirements, and greater enforcement efforts are necessary.
Latest Developments in Mental Health Parity Law
Recognizing how much work still remains to achieve mental health parity, the Department of Labor, along with HHS and the Treasury Department, have proposed a rule designed to make parity a reality for more people seeking MH / SUD services.
The proposed rule would require group health plan providers to present actual data showing how a person’s access to treatment is affected by the limitations placed on benefits. Attention will focus on how provider networks are constructed and whether they promote access to benefits.
The rule would also change how NQTL criteria are analyzed for purposes of compliance and set forth required content elements for analysis.
Parity in Texas
Under the Texas Administrative Code, a health benefit plan that provides both M / S and MH / SUD benefits must comply with the following regarding lifetime aggregate or annual dollar limit restrictions:
- If there are no limits or limits on less than one-third of the medical/surgical benefits, there can be no limits on MH / SUD benefits.
- If there are limits on at least two-thirds of M / S benefits, they must be applied in a way that does not distinguish mental health / substance use disorders, or there must not be a more restrictive limit on MH / SUD benefits.
Non-quantitative treatment limitations imposed on MH / SUD benefits must be similar to and applied no more stringently than NQTL applied to M / S benefits.
What You Can Do if a Parity Violation is Suspected with Regard to MH / SUD Benefits
Under current federal and state laws, many but not all health benefit plans are required to provide MH / SUD benefits. If your health plan has benefits for MH / SUD, they must be as easy to access as your other medical benefits. Any limitations on mental health benefits can be no more restrictive than the limitations on M / S benefits.
If you’ve had an insurance claim for mental health or substance use treatment denied and you believe the treatment limitations violate parity requirements, Berg Plummer Johnson & Raval, LLP may be able to help you get compensation. Our Texas health insurance lawyers have decades of experience helping clients obtain the benefits they are entitled to. In Houston, contact Berg Plummer Johnson & Raval, LLP to discuss your health benefit plan and how to get your claim covered.