Parity law offers opportunity, challenges

The 2008 enactment of the Mental Health Parity and Addiction Equity Act was a major step toward ending insurance discrimination against those who need treatment for mental health and substance use disorders. While many more Americans will be able to access services, we anticipate that there will be challenges ahead for both patients and their psychologists as the mental health parity law is implemented.

The law extends the 1996 parity requirements to both financial requirements and treatment limitations. Group health plans of 50 or more employees that provide both medical/surgical and mental health/substance use disorder benefits may not apply any financial requirements or treatment limitations to mental health/substance use disorder benefits that are more restrictive than those imposed on medical/surgical benefits.

In February, the federal government published a rule that provides compliance guidance for group health insurance plans required to follow the law. The rule clearly shows that federal regulators worked to implement the law as the APA Practice Organization urged. For example, APAPO had strongly recommended that the rule prohibit separate deductibles and out-of-pocket maximums for mental health and substance use disorder benefits since such separate limits — even if they were equal — would violate the spirit of the law. Regulators agreed: The interim rule prohibits separate deductibles and out-of-pocket maximums for mental health and substance use disorder benefits.

The federal regulators also looked beyond typical financial requirements and treatment limitations to apply the law so it prohibits any type of requirement or limitation that would violate the law’s intent. APAPO was pleased that the regulations, for example, prohibit the classification of psychologists as specialists for purposes of charging a higher co-pay.

The federal rule pertaining to the law will begin to apply on Jan. 1. APAPO will now work to ensure that insurance companies comply. We do not anticipate major problems regarding compliance with financial requirements such as deductibles, co-payments and coinsurance or with treatment limitations which are expressed numerically, such as number of outpatient visits allowed annually. However, a major focus for us will be those "non-quantitative treatment limitations," or NQTLs, where the standard and regulation is vague enough to portend years of fighting insurers’ interpretations. Examples of NQTLs (from "Kibble & Prentice Compliance Alert," June 9, 2010) include:

• Medical management standards limiting or excluding benefits based on medical necessity.

• Standards for provider admission to participate in a network.

• Plan methods for determining usual, customary and reasonable charges.

The rule requires NQTLs on the mental health side to be "comparable" to the medical/surgical side. Rather than compare the management of psychotherapy to physician services, one major insurer is attempting to equate it to managing physical therapy benefits, which typically are managed more stringently than physician services. We’re also aware of another insurer arguing for an increase in medical necessity evaluations. This company is requiring mental health consumers to undergo a medical necessity review after eight or 10 sessions. (Telephonic reviews may also raise HIPAA issues; we will explore this topic in more detail in a future issue of APAPO’s e-newsletter Practice Update.)

APAPO is and will be following these developments very closely and working to ensure that the progress made so far with the law’s passage and the crafting of the guiding federal rule indeed become reality. For more information about parity law implementation, visit the Mental Health Parity section of APA Practice Central.

Access to services shouldn’t be limited only to those patients determined to jump through hoops. And it is crucial that insurers put in place a system that ensures privacy invasion is minimal as they determine who needs care. Should you encounter issues with NQTLs or other parity provisions, please contact the Practice Directorate by e-mail or (202) 336-5886.

As always, I welcome your comments or concerns about these issues at my e-mail.