Equal benefits for substance use and mental health treatment
Before 2008, health insurance plans traditionally excluded or limited coverage for treatment of substance use and mental health disorders. That changed with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Since then, most health plans have been required to cover such treatment in ways that are comparable to medical and surgical benefits.
"My Administration has made behavioral health a priority and taken a number of steps to improve the prevention, early intervention, and treatment of mental health and substance use disorders," wrote Barack Obama in a memo about the MHPAEA. "These actions are especially important in light of the prescription drug abuse and heroin epidemic as well as the suicide and substance use-related fatalities that have reversed increases in longevity in certain populations."
The MHPAEA originally applied to group health plans sponsored by employers. In 2010, the Affordable Care Act extended parity to individual health insurance, including policies sold in health insurance exchanges.
Key changes made by the law
Parity affects almost every way that people access treatment for substance use and mental health conditions. For example:
- Deductibles and copayments for these conditions can't be more restrictive than the predominant benefits for substantially all medical and surgical benefits.
- If health insurance coverage includes out-of-network coverage for medical and surgical benefits, it must also provide out-of-network coverage for substance use and mental health benefits.
- Quantitative limits — such as the number of covered clinic visits — can't be more restrictive for substance use and mental health treatments than for other treatments.
- Requirements for proof of medical necessity and prior authorization for treatment can't be more restrictive for substance use and mental health conditions.
- Health insurers may not impose a lifetime or annual dollar limit on substance use and mental health benefits that's lower than the limits for other benefits.
Exceptions to the law's requirements
The MHPAEA applies only to larger group health plans that choose to include substance use and mental health treatment in their benefits. The law doesn't require such plans to cover substance use and mental health treatments in the first place.
In addition, the MHPAEA doesn't apply to:
- Self-insured private employers with 50 or fewer employees
- Larger employers who self-fund their health insurance and meet requirements for opting out of the law
- Plans that claim a one-year exemption to the law due to cost increases of at least 2 percent
Implications for nonprofits
If your organization provides substance use and mental health treatment — or pays for such treatment —check health insurance plans carefully. Look for lack of parity in:
- Covered visits
- Out-of-network coverage
- Prior authorization
- Proof of necessity
- Dollar limits
- Requirements for written treatment plans
You might ask the board or a special committee of board members to handle ensuring parity in the categories outlined above. Remember, too, that health plans covered by the MHPAEA must disclose — in writing — their reasons for determining medical necessity and denying coverage.
This article draws on the expertise of Grace Davies, a Minneapolis-based attorney with special interest in product liability, medical malpractice and employment discrimination.