Health plans must provide the same level of coverage for mental health and substance use disorder services as they do for medical and surgical treatment, according to new federal regulations.
The long-awaited final rule, jointly released by the departments of Treasury, Labor, and Health and Human Services on Nov. 8, implements the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act passed in 2008.
Kathleen Sebelius
The final rule makes clear that insurers who offer mental health and addiction services cannot charge higher copayments or deductibles or impose stricter visit limits. Insurers also cannot place greater restrictions on where individuals can go to seek these services. For instance, if a health plan allows its members to see a cardiologist out of network, then they must be able to see a psychiatrist out of network, too.
"Today, parity is the law of the land and we’ve already seen significant improvements," HHS Secretary Kathleen Sebelius said during a press conference.
Most large employer health plans have already eliminated higher cost sharing for inpatient behavior health care, Ms. Sebelius noted.
The final rule requires health plans to apply parity to intermediate levels of care, such as residential treatment and intensive outpatient settings. And it requires plans to disclose to their members the standards they are using in setting benefits and the reasons for denying a claim.
In the final rule, regulators eliminated a provision that had allowed insurers to make exceptions to certain benefit requirements based on "clinically appropriate standards of care." Federal regulators made the change after hearing from clinical experts that the exception was unnecessary and could be abused by health plans.
The new rules will affect most health plans in the employer and individual markets, including plans being sold on the new health insurance exchanges. The regulation does not require health plans to cover mental health and addiction services, but if plans do cover these services, then they must be in parity with medical and surgical benefits.
However, under the Affordable Care Act, plans offered to individuals and small groups on the health insurance exchange must include mental health and substance use disorder services as part of their essential benefits package.
The rules don’t apply to small employer plans offered outside of the health insurance exchanges or to the Medicare or Medicaid programs. However, the government issued separate guidance in January 2013 on how mental health parity would apply to Medicaid and the Children’s Health Insurance Program (CHIP).
The federal government issued an interim final rule on mental health benefits parity in 2010, but the requirements were not uniformly followed and insurers often manipulated the rules, according to the American Psychiatric Association (APA). Some insurers evaded the requirements by providing patients with vague medical necessity standards, forcing them to go through lengthy approval procedures for services, and instituting complicated appeals processes, APA officials said.
"The final rule provides a crucial step forward to ensure that patients receive the benefits they deserve and are entitled to under the law," Dr. Jeffrey Lieberman, APA president, said in a statement. "In addition to providing equal benefits for mental illness as physical illness, I am hopeful that there will be strong monitoring and enforcement at both the state and federal levels."
Federal officials said the final rule is unlikely to have a major impact on health plan costs since mental health and addiction services make up only a small part of the services they cover.
The final rule will apply to health plans for plan or policy years starting on or after July 1, 2014. However, plans must continue to comply with the provisions of the 2010 interim final rule.
mschneider@frontlinemedcom.com
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