Five years after parity, gaps remain

Despite passage of the Mental Health Parity and Addiction Equity Act in 2008, and expansion of its provisions through the Affordable Care Act in 2010, parity issues still impede patient access to needed psychological care. The release of the interim final rule in February 2010 was a bold step forward for psychologists and consumers of psychological services, with its extension of parity protections to non-quantitative treatment limitations, such as pre-authorization requirements. Federal regulators adopted the APA Practice Directorate's suggestion that parity be applied in a straightforward manner and ruled that requirements and limitations on mental health and substance use benefits cannot be applied in a more restrictive manner than those for medical and surgical benefits. But after an early victory with the Illinois Department of Insurance blocking authorization requirements by Blue Cross Blue Shield of Illinois, enforcement of the interim final rule has been lacking.

Since the interim final rule went into effect, the APA Practice Directorate and APA Practice Organization have worked to ensure parity, focusing major efforts on the impact on patient access to care and patient financial burden caused by certain reimbursement practices that companies appear to apply only to mental health care.

This effort started with a complaint letter to the federal parity enforcement agencies (the Departments of Health and Human Services, Labor and Treasury) in October 2011 about Blue Cross Blue Shield of Florida's alleged parity violations and the impact on patients. Subsequently, in collaboration with state psychological associations, we have filed similar complaints with federal and state agencies about alleged parity violations in a dozen states.

However, those agencies have not concluded a single investigation or taken any enforcement action on these complaints.

Our other advocacy efforts include:

• Working with the Massachusetts Psychological Association and Massachusetts Neuropsychological Society to get Blue Cross Blue Shield of Massachusetts to recognize that it cannot deny neuropsychological assessment services to patients with a mental health diagnosis. 
• Lodging complaints with several third-party payers questioning practices that discourage psychologists from providing appropriate care to patients who need longer therapy sessions.
• Calling for the Centers for Medicare and Medicaid Services to include mental health and substance use disorder services, including behavioral health treatment, among the 10 required health insurance benefit categories. In February, when the U.S. Department of Health and Human Services released the final rule on essential health benefits — a core package of services mandated by the Affordable Care Act — mental health parity standards were included.

We continue to advocate for a stronger, more enforceable final parity rule, which the Obama administration has announced will be released by the end of this year. On April 24, I sent a letter to the two main federal parity enforcement agencies — the Departments of Health and Human Services (HHS) and Labor (DOL) — suggesting several changes for the final parity rule that would speed enforcement and clarify consumer protections. To encourage a more enforceable parity rule, HHS and DOL need to hear from psychologists about how parity issues are affecting their patients' access to psychological services. Regulators claim to have received few parity complaints, though APA Practice staff have received hundreds of calls and emails about these issues. The federal agencies will not strengthen enforcement in the final rule if they believe mental health providers and patients are satisfied with how the current rule is working.

Complaints can be emailed to the general email address for DOL at and HHS. For more information, see the April 25 PracticeUpdate article.

APAPO will continue to update members in upcoming issues of the PracticeUpdate e-newsletter about our further advocacy efforts.