Since you asked...about implementation of the federal parity law
by Government Relations Staff
June 30, 2010 — The Paul Wellstone and Pete Domenici Mental Health Parity & Addiction Equity Act (MHPAEA) became law in October 2008. With the federal government’s publication of the Interim Final Rule (IFR) to implement this full mental health insurance parity law, clear guidance and strong consumer protections become effective for health plan years beginning on or after July 1, 2010. For most plans, this means that the IFR will apply on January 1, 2011.
A group of managed behavioral health organizations filed a lawsuit against the federal government in the spring of 2010 to block implementation of the IFR. On June 21, a judge with the U.S. District Court for the District of Columbia dismissed the lawsuit, allowing the regulatory process governing the federal parity law to proceed.
Practicing psychologists have raised numerous questions about the federal parity law and its impact on consumers of psychological services. This question-and-answer article addresses several common questions from practitioners.
Q: Can I assume that all my patients are covered by the federal parity law?
A: No. MHPAEA covers most but not all health plans. The federal law applies to group plans sponsored by employers of more than 50 employees. State and local government employee plans may opt out of the federal parity law, though few of these plans have done so.
Further, if a plan does not cover mental health benefits, the law would not pertain to your patients in such a plan. Fortunately, the vast majority of health plans do cover mental health services.
For a detailed summary of this and other key provisions of the law, read “Summary of the New Parity Law" on our Practice Central website. Patients who are unsure if their employer covers their mental health care at parity with their medical/surgical care should speak with their company’s Human Resources office.
Q. Is it true that health plans may drop mental health benefits rather than comply with the new consumer protections?
A. Like other federal laws, MHPAEA does not mandate the inclusion of health or mental health benefits in health insurance plans. Instead, the parity law contains “coverage conditions” that apply only if a plan covers mental health services. Some 97 percent of group health plans do cover mental health services. We do not expect implementation of the interim final rule governing the federal parity law to have any substantial impact on the nearly universal extent of mental health services coverage.
Q. In the past, some parity laws applied only to the so-called "biologically-based" disorders involving serious mental illness such as schizophrenia or bipolar disorder. Is it true that the new parity law requires insurance companies to extend parity coverage to a broader range of mental health services?
A. Under MHPAEA, parity requirements apply to all services covered by a plan, not just a narrow list of SMI diagnoses. The federal law “wraps around” state laws like New York’s Timothy’s Law. By that we mean that insurance plans in New York, for example, must still cover the state’s list of “severe mental illnesses” in their benefit packages. For health plans in New York provided by employers of more than 50 people, MHPAEA further requires any additional mental health/substance use services covered by the plan to be covered the same as medical/surgical services.
Although not a common practice, an insurer may exclude coverage of particular diagnoses — for example, autism or ADHD – in its coverage agreement with an employer. It is important to check with the employer’s Human Resources office to verify that an exclusion applies.
Q. My patient’s insurance company does not require pre-authorization for outpatient medical/surgery visits to primary care physicians such as internists and family physicians, but is requiring pre-certification of outpatient psychotherapy visits in order to be reimbursed for these services. What should I do?
A. The Interim Final Rule (IFR) should address this issue for most health plans beginning January 1, 2011. The IFR makes clear that mental health benefits cannot be managed more stringently than medical/surgical benefits. If a plan imposes pre-authorization requirements on mental health benefits that it does not impose on medical/surgical benefits, that plan would be violating the parity law.
Unfortunately, some patients may continue experiencing problems with pre-authorization until the IFR takes effect for their health plan – again, generally on January 1, 2011. If the problem persists at that time, your patient may wish to contact his or her Human Resources office for assistance.
Summary of the IFR implementing the MHPAEA (PDF, 56 KB) (This content is accessible to APAPO members)
Q. My patient’s insurance plan has an arbitrary limit on the number of outpatient mental health sessions per year. What should I do?
A. Clearly a plan that continues to use a prior mental health benefit limit — for example, 30 inpatient days and 20 outpatient sessions per year — is in violation of the law if such limits are not placed on medical/surgical benefits. You or your patient may wish to contact the health plan to urge compliance with the IFR. Alternatively your patient may wish to contact his/her Human Resources office for assistance.
Q. My patient’s health plan is requiring a higher patient copayment for my services because the plan considers me a “specialist.” Does the new law consider me a specialist?
A. No. The Interim Final Rule (IFR) explains that a plan that requires mental health providers to be classified as specialists for the purposes of calculating copayments is violating the law.
Q. Should my patient or I report noncompliance by an insurer to the government?
A. Beyond speaking with a Human Resources office and the insurance company, you and/or a patient may file a formal complaint with the federal government.
Complaints about insurance plans regulated under state law may be made via a toll-free Health & Human Services help line at 1-877-267-2323, extension 61565, or by e-mail.
For “self-funded” plans governed by the federal law known as ERISA (generally those of large employers), the Labor Department may be reached at 1-866-444-3272 or with an online form.
A word of caution to temper expectations: There may not be adequate staffing to investigate each complaint received.