Okay, so there's "parity". What does that boil down to, and what problems can we foresee?
This is the very brief description of the Mental Health Parity and Addiction Equity Act from the Department of Labor site:
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. MHPAEA supplements prior provisions under the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits.
I tried to read a little about the details of the Act, but it wasn't easy. From what I could glean, from the DOL site, as well as CMS, there's good news and there's bad news.
The good news:
-The criteria and standards for medical necessity determinations must be made available upon request
-Ditto the reason for a denial
-There can't be a separate deductible for Med/Surg and Mental Health/Substance; they need to be combined.
-There were already parity requirements in place with respect to aggregate lifetime and annual dollar limits, but these now apply to Substance treatment
-If your plan covers Out-of-Network providers for med/surg, it needs to cover out-of-network for MH/Sub.
The bad and confusing news:
-The Act does not mandate that a plan provide MH/SUD benefits.
-The Act does not apply to issuers who sell health insurance policies to employers with 50 or fewer employees or who sell health insurance policies to individuals.
-The regulations provide that the “predominant/substantially all” test applies to six classifications of benefits on a classification-by-classification basis. The regulation also includes other rules and definitions that are necessary in order for plans, issuers and their advisers to apply this general parity test.
This is where it starts to careen off into the stratosphere. I truly don't get the test and classifications, but I'll share the little bits and pieces that I partially grasp.
The general rule is that a plan may not impose a financial requirement or quantitative treatment limitation applicable to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or quantitative limitation of that type applied to substantially all medical/surgical benefits in the same classification.
The six classifications of benefits are:
Inpatient in-network;
Inpatient out-of-network;
Outpatient in-network;
Outpatient out-of-network;
Emergency care;
Prescription drugs.
There are also Non-Quantitative treatment limitations, including medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, plan methods for determining usual, customary, and reasonable charges, refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols), and exclusions based on failure to complete a course of treatment.
The test for determining parity refers to levels of types of financial requirements or treatment limitations. The level of a type of financial requirement or treatment limitation refers to the magnitude of the type of financial requirement or treatment limitation. For example, different levels of coinsurance include 20% and 30%, different levels of copays include $15 and $20, or different levels of an episode limit include 21 inpatient days per episode and 30 inpatient days per episode.
To determine if a quantitative financial requirement (such as a copay) or quantitative treatment limitation (such as a visit limit) is permissible, the parity analysis must be applied for that type of financial requirement or treatment limitation within a coverage unit for each of the six classifications of benefits separately. A coverage unit refers to the way in which a plan groups individuals for purposes of determining benefits, or premiums or contributions (for example, self-only, family, employee plus spouse).
If a type of financial requirement or quantitative treatment limitation applies to substantially all medical/surgical benefits in a classification (for example, if a copay applies to substantially all medical/surgical benefits), then it may be permissible for that requirement or limitation (the copay) to apply to mental health or substance use disorder benefits. Generally, a financial requirement or treatment limitation is considered to apply to substantially all medical/surgical benefits if it applies to two-thirds or more of the medical/surgical benefits for the same classification and coverage unit.
The predominant level of a type of requirement or limitation applicable to medical/surgical benefits within a classification is the most restrictive level of the requirement or limitation that can be imposed on mental health or substance use disorder benefits within that classification...If, for example, for self-only coverage a $10 copay is the predominant level of copay that applies to substantially all inpatient in-network medical/surgical benefits, that is the most restrictive copay that can apply to inpatient in-network mental health or substance use disorder benefits.
A plan may not create sub-classifications for generalists and specialists to determine separate predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits. However, if the predominant level of a type of financial requirement that applies to substantially all medical/surgical benefits in a classification is the one charged for a medical/surgical specialist, then that “specialist” financial requirement can be applied for all mental health or substance use disorder benefits within that classification. On the other hand, if the predominant level of a type of financial requirement that applies to substantially all medical/surgical benefits in a classification is the one charged for a medical/surgical generalist, then the financial requirement charged for all mental health or substance use disorder benefits within that classification cannot be higher than the “generalist” financial requirement for medical/surgical benefits.
Let's try this. A patient comes to see me. I'm classified as Outpatient, Out-Of-Network. The patient is single, so that's a self-only coverage unit. He is also diabetic, and his endocrinologist is also out-of network. His insurance pays 80% (the financial requirement) of the usual and customary fee (the non-quantitative treatment limitation) for endocrinologists in his region, and he is responsible for the rest. That's the level of coverage. And the percentage payment is the type of financial requirement (as opposed to if he had to pay a copay).
But two thirds of self-only covered patients in the region who are treated by endocrinologists have out of network coverage (in that plan or a different one?) that pays only 70% of the usual and customary fee, making 70% the most restrictive level of requirement. So when he submits my bill to his insurance, he will only be reimbursed 70% of the usual and customary fee. (Is this the customary fee for psychiatrists, or endocrinologists?) And if 2/3 of coverage for endocrinologists is at the 70% rate, but 2/3 of coverage for all outpatient treatment is at an 80% rate, then my bill will be reimbursed at the 80% rate.
Well, I'm glad we cleared that up.
I'm wondering if the upshot will be that MH/Sub just stops being covered. Period. There's no requirement for an insurer to cover it. The MHPAEA only requires that if it's covered, it has to be covered with parity, as defined in the very complicated details that I don't understand.
Moreover, it's obvious that insurance companies will find ways to apply these byzantine rules to their advantage.
The real twister here is that we're comparing apples and kumquats. I'm not referring to the question of whether psychiatry is a "medical" endeavor. I'm only considering the type, and more importantly, frequency, of treatment used in psychiatry, vs. say, cardiology (that would be a level of treatment, and a quantitative treatment limitation).
Admittedly, I'm an anomaly, because I see some patients as frequently as 4 times per week in psychoanalysis (more on this in a future post). I don't think patients visit their cardiologists 4 times per week over the course of a number of years. So does "no more restrictive" mean that my patients will be covered for as many visits per year as they would make to a cardiologist, assuming they needed one?
"Because of the MHPAEA, we are only required to cover you for a maximum of 4 sessions per year, rather than our previous cap of 40 sessions per year, because you see your cardiologist 4x/year."
What a windfall for the insurance companies. Remind me to buy stock in United healthcare.
And don't forget to join POLL, our Psychiatry Online Lifelong Learning journal club over on LinkedIn.