Below is the national Mental Health America Policy Position and Call to action regarding mental health parity in health insurance.1 This position paper sets the context for policy work on parity. The key issues are:
The Metal Health America Policy Position and Call to Action was adopted in September 2006, before the passage of the Mental Health Parity and Addiction Equity Act in 2008. However, as will be outlined in this toolkit, there are still gaps in mental health and substance abuse parity and the principles of the policy statement are still relevant. On a practical note, there are citations in the policy paper that are that continue to be relevant and valuable in making the argument for full parity.
All people in America should have a right to health-care benefits, including needed behavioral health services. The Mental Health America calls on federal and state government to ensure, as a matter of law, that public and private health plans afford people access to needed behavioral health care and treatment on the same basis. Such services should be subject to the same terms and conditions as care and treatment for any other illness, without regard to diagnosis, severity, or cause.
All people in America should have a right to health-care benefits, including needed behavioral health services. The Mental Health America calls on federal and state government to ensure, as a matter of law, that public and private health plans afford people access to needed behavioral health care and treatment on the same basis. Such services should be subject to the same terms and conditions as care and treatment for any other illness, without regard to diagnosis, severity, or cause.
Mental health is essential to leading a healthy life and to the development and realization of every person's full potential. Yet mental illness and substance-use disorders are leading causes of disability and premature mortality in the United States. As the President's New Freedom Commission on Mental Health observed in its final report2, mental disorders are "shockingly common." Most people are affected in some way by mental illness at some point in their lives.
With striking scientific advances over the last half century, behavioral health problems are now reliably diagnosed, and there is a range of treatments for virtually every such disorder. Those treatments have efficacy rates comparable to or exceeding those for many medical and surgical conditions. Yet all too often people with diagnosable mental disorders do not seek treatment. "Concerns about the cost of care - concerns made worse by the disparity in insurance coverage for mental disorders in contrast to other illnesses - are among the foremost reasons why people do not seek needed mental health care," the Surgeon General observed in the landmark 1999 report on mental health.3
Health insurance plans, from private individual and group coverage to the Medicare program, have long imposed barriers that limit access to needed behavioral health care for both mental and substance-use disorders, with far-reaching and often tragic results. No comparable barriers limit access to needed care for other illnesses. That such blatant discrimination continues to flourish -- more than a decade after enactment of the Americans with Disabilities Act, some forty years after the adoption of the first modern civil rights' laws, and nearly a century since this organization's establishment as a movement based on principles of social justice -- attests to the deep-rootedness of the stigma surrounding behavioral health disorders. But that such ongoing arbitrary discrimination is countenanced by federal law is nothing short of shameful.
The widespread practice of providing unequal coverage for behavioral health and other medical care not only limits access to needed care, but subjects many Americans to the risk of major financial losses from out-of-pocket costs. At the most profound level, these practices reinforce the poisonous stigma underlying disparate treatment of "others". That disparate coverage of behavioral health should be routine, and that discrimination against people with or at risk of behavioral health disorders should be lawful, is not only morally offensive in itself, but fosters a climate that tolerates and even encourages other forms of discrimination and weakens the fabric of equal-opportunity laws.
No rational basis supports these discriminatory health-insurance practices, which have drawn criticism from voices ranging from President George W. Bush to Fortune 500 chief executive officers.4 A landmark report by the National Business Group on Health recommends employers equalize their medical and behavioral benefit structures given evidence that parity yields significant clinical benefit without increasing overall healthcare costs.5
Lack of understanding regarding mental health and deep-rooted stigma help explain why it is still so common for health plans to place greater restrictions on treating behavioral health disorders than on other illnesses. While enlightened business leaders in some industries and communities have voluntarily provided parity protection for their workforces, voluntary measures are not an answer to the widespread discrimination facing most insured Americans. Thus, Mental Health America supports insurance-parity legislation.
Congress took a first step toward ending such discriminatory insurance practices when it enacted the Mental Health Parity Act of 1996. The Act established the principle that there should be no disparity in health insurance between mental-health and general medical benefits. By its terms, however, the Act provided only that employer health plans that cover more than fifty employees and that offer mental health benefits may not impose disparate annual or lifetime dollar limits on mental health care.
The 1996 Act represented an important milestone, but has not produced fundamental changes. People with or at risk of behavioral-health disorders still face widespread, arbitrary discrimination in insurance plans. As the General Accounting Office (GAO) reported in reviewing the Act's implementation, the vast majority of employers it surveyed complied with the 1996 law, but substituted new restrictions and limitations on mental health benefits, thereby evading the spirit of the law.6 As GAO documented, employers routinely limited mental health benefits more severely than medical and surgical coverage, most often by restricting the number of covered outpatient visits and hospital days, and by imposing far higher cost-sharing requirements.7
Although subsequent efforts to enact a comprehensive federal parity law have been unsuccessful, the federal Government further advanced the principle of parity by requiring insurers to equalize behavioral-health and other health benefits under the Federal Employee Health Benefits program (FEHB), which covers federal employees (including Members of Congress), retirees and dependents.8
Most states have adopted laws requiring parity between mental health and general health benefits in group health insurance. But those state laws vary widely in scope, and, under federal law, do not govern the health plans of the many employers who elect to self-insure.9
Those opposing parity legislation often assert that it will add to the cost of health care. But as the National Business Group on Health observed in its employer's guide to behavioral health services, a number of parity studies have found that equalizing specialty behavioral health and general medical benefits will either not increase total healthcare expenses at all or will increase them by only a very modest amount of total healthcare premium.10 The real cost lies in not treating behavioral health disorders. As the National Business Group noted, the indirect costs associated with mental illness and substance-use disorders - excess turnover, lost productivity, absenteeism and disability - commonly meet or exceed the direct treatment costs, and have been estimated to be as high as $105 billion annually.11
The discrimination in health insurance against people with or at risk of behavioral health disorders; the lack of real protection in current law against such discrimination; and the loss of life, health, and productivity attributable to these insurance barriers make it critical that Congress ensure that public and private health plans equalize medical and behavioral health benefit structures. Some attack parity legislation targeting employer-provided insurance as inappropriate regulation of benefits provided at the employer's discretion. But these discriminatory practices frustrate the compelling governmental interest of protecting all Americans equally, at whatever level of coverage the employer or the insured can afford. Indeed, federal law subsidizes employers through the federal tax code for providing health insurance to employees (allowing the cost of insurance as an ordinary business expense).12 It is wholly appropriate for Congress to condition entitlement to such tax benefits on employers' providing health benefits in a non-discriminatory manner.
Facing opposition to parity proposals, legislators have in some instances limited the scope of such measures and provided parity protection to only certain populations. Sound public policy aimed at achieving fairness is certainly not realized, however, when the law affords fair and equal treatment to some and not others. Mental Health America, therefore, does not support enactment of legislation that limits parity protection only to individuals who have specified diagnoses.13
Compelling principles dictate the adoption of comprehensive parity legislation. These include recognition that:
The Mental Health America Board of Directors approved this policy on September 8, 2006. It will remain in effect for five (5) years and is reviewed as required by the Mental Health America Prevention and Adults Mental Health Services Committee. Expiration: September 8, 2011
A September 2010 article by Colleen L. Barry, Haiden A. Huskamp and Howard H Goldman in Milbank Quarterly gives a summary of the political milestones in federal mental health and addiction insurance parity prior to the passage of the 2008 Mental Health Parity and Addiction Equity Law.14 Some historical highlights of parity policy:
In 2008, the Medicare Improvements for Patients and Providers Act was passed (effective January 1, 2010) eliminating Medicare's discriminatory copayments for mental and physical health.
In 2009, the Patient Protection and Affordable Care Act (health care reform) was passed. The Act is expected to expand health care coverage to an additional 32 million citizens and legal immigrants by 2019 through a combination of state-based private insurance exchanges and a Medicaid expansion. In addition, the new law includes a number of reforms to curb harmful insurance company practices as well as provisions to slow the growth of health care costs and improve quality of care.15 Some key parity provisions:
In September 2010, a number of mental health advocacy organizations including Mental Health America released the Parity Toolkit for Addiction & Mental Health Consumers, Providers & Advocates, Parity Implementation Coalition, September 2010, First Edition.16 This excerpt from the September 2010 Toolkit gives a summary of the legislation.
Background on Parity
Most Americans with health insurance face greater barriers in accessing services for mental illness and addiction than they face for accessing care for other medical conditions. The majority of health plans impose higher out of pocket spending requirements and more restrictive treatment limitations on addiction and mental health benefits.
Today, with new technologies like MRIs and PET scans that allow scientists to look inside the brain, the evidence that mental illness and addiction are brain diseases is more compelling than ever before. Unfortunately, reimbursement policy has not kept up with science.
Since 1992, advocates like you have fought for health care equality for those with addiction and/or mental illness. A partial mental health parity law was passed in 1996 that was a significant step forward.
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 to correct discriminatory health care practices against those both with a mental illness and/or addiction. Significantly, the law aims to curb both the financial and non-financial or "non-quantitative" ways that plans limit access to addiction and mental health care. Individuals with mental illness and/or addiction, their families, professionals in the field and employers worked together to pass the law.
In the end, turning a law into REAL lifesaving addiction and mental illness benefits means we have to fight for our new rights and benefits. This is OUR responsibility.
Brief Summary of the Parity Law
Here are ways the law requires addiction/mental health and medical benefits to be no more restrictive:
Brief Summary of the Regulatory Process
Regulations are the written rules by which agencies implement law. Interim final regulations (IFR) implementing parity were issued February 2, 2010. The regulations give specific instructions for implementing the parity law.
Regulations are the written rules by which agencies implement law. Interim final regulations (IFR) implementing parity were issued February 2, 2010. The regulations give specific instructions for implementing the parity law.
"Interim final regulations" have the effect of binding law when they are issued. Parity regulators have said they will issue additional regulations, but we do not know when or if they will definitely come out. Until additional regulations are released, plans must comply with the existing regulations.
The regulations are effective for plan years beginning on or after July 1, 2010. Many plans start their plan year in January so the full effect of parity will not begin to be experienced in many markets until January 1, 2011.
6 classifications of benefits
The regulations define a 6-part classification scheme for benefits:
If a plan provides medical/surgical benefits in any or all of the above categories it must provide mental health/addiction benefits in the same categories.
Although the 2008 Mental Health Parity and Addiction Equity Act is a huge milestone in the fight for equal treatment of medical and mental illnesses, there are important provisions of the law and specific exemptions that call for continued advocacy at the state (and national) level.
Some important examples of gaps in coverage remaining after the passage of MHPAEA that are actionable by advocates are (as noted above):
As noted above, the federal health care reform legislation greatly expands health insurance but does not erase the gaps in federal parity regulation. However, both the MHPAEA and federal health care reform legislation allow states to make stronger parity regulations. Therefore, real opportunity exists for advocacy at the state level to require every insured life to be covered by effective mental health and substance abuse services without regard to diagnosis, severity, or cause.
Many states have parity laws and regulations that go beyond federal parity even as it is outlined in the MHPAEA.
To see the Departments of Insurance in the five states with the best parity laws:
See also the January 2007 publication State Mandates for Treatment for Mental illness and Substance Use Disorders - http://store.samhsa.gov/product/SMA07-4228
Section 5: Strategies for Advocacy at the State Level
Two overarching advocacy challenges remain for state advocacy in the post 2008 passage of mental health parity:
Both of these challenges require education of consumers, family members, employers, purchasers, clinicians, policy makers, and the general public regarding the benefits of identifying and treating issues related to mental health and substance abuse.
While some states have regulations that go above and beyond the national parity law (see Section 6), some states have few or no parity regulations and therefore little experience in regulation in a parity milieu. For example, for state regulated plans, the state insurance commissioners have primary responsibility of enforcement of parity. Now they will be asked to enforce a federal statute, possibly without a state statute or regulation to support them. Therefore, there may be states that decide to pass a statute or develop regulations that allow them to more easily enforce the federal statute and regulations. However, if state insurance commissioners do not enforce the federal statute and regulations then the U.S. Department of Labor has secondary authority to enforce. In order to avoid confusion, all consumers and providers can call the department of Labor with a compliance issue and they will help to resolve the problem.
Advocacy efforts around state implementation of federal parity regulations should include:
Broader advocacy to improve mental health and substance abuse coverage includes tactics that advocates from a wide spectrum of interest groups use as well as some targeted strategies.
In many ways states have led the way to mental health insurance parity with legislation that expanded coverage for certain diagnoses and certain categories of insured lives. With the 2008 and 2009 MHPAEA, Medicare parity improvements, and federal health care reform; the federal government has greatly expanded the federal role in promoting mental health parity. States with parity regulations provided important data to undergird arguments for federal parity. It is incumbent upon state advocates to push the envelope even further until every individual has access to high-quality mental health and substance abuse prevention and treatment services.