Mental Health Parity Under the Affordable Care Act
Affordable Care Act and Mental Health Parity and Addiction Equity Act
By Judy Watkins, Esq., Masters of Arts Candidate, Mental Health Counseling
A major focus of the Affordable Care Act (ACA) is to improve insurance coverage offered for mental health and substance abuse assistance. This has been facilitated by incorporation and expansion of the federal Mental Health Parity and Addiction Equity Act (MHPAEA) into the ACA. It is important to note that MHPAEA does not apply to all health plans provided by public or private employers. Some exceptions include but are not limited to employers with fifty associates or under, or health insurance carriers who provide health coverage to employers with fifty employees or less, (Fact Sheet, 2010). Also, the ACA does not specifically mention counselors or any other mental health professionals specifically, (American Counseling Association, 2010).
MPHAEA requires group health plans and health insurance providers (collectively referred to as plans), which offer medical and/or surgical coverage, as well as, mental health and/or substance abuse disorder benefits, to have financial requirements and/or treatment limitations for mental health or substance abuse treatment that are not more restrictive than those applied to other medical and/or surgical claims, (42 U.S.C. § 300gg-26(a) (A)(i) and (ii)).
For example, the financial requirements provision means that plans cannot charge more for “…deductibles co-payments, coinsurance, and out-of-pocket expenses…” for mental health and substance abuse services as compared to most other medical care, (42 U.S.C. § 300gg-26(a)(3)(B)(i)). In addition, treatment limitations encompass restrictions on the amount of visits, treatment regularity, days of coverage or comparable parameters regarding the range or length of treatment, (42 U.S.C. § 300gg-26(a)(3)(B)(ii)).
Another major comparison is nonquantitiative treatment limitations which when applied to mental health and substance abuse disorder benefits cannot differ from those utilized for other medical services, 45 C.F.R. § 146.136(4)(i). Some examples of nonquantiative treatment limitations include: “…(D)[s]tandards for provider admission to participate in a network, including reimbursement rates; (E) [p]lan methods for determining usual, customary, and reasonable charges;...”, 45 C.F.R. § 146.136(4)(ii)(D & E).
The Sentinel Project
Even though the federal government has provided significant direction, numerous questions regarding parity still remain for providers, regulators, insurance carriers, and most importantly consumers. Especially since New Jersey does not have a health insurance exchange and/or a federally funded consumer aid program, the Sentinel Project (Project) was formed to help ensure that the public can utilize the health services provided under the ACA. The Project is a partnership with Seton Hall Law School and the New Jersey Public Interest Law Center, which is funded by the Robert Wood Johnson Foundation, (“The Sentinel Project”, (n.d.)). To furnish some clarity on the status of parity in New Jersey, the Project issued a report based upon several years of research, (Jacobi & Ragone, 2016). A conference was held on September 16, 2016 at Seton Hall Law School in Newark, New Jersey to further explore the topic and discuss the Project’s findings. Presenters and attendees included government officials, industry representatives, advocates, and consumers, (“The Puzzle of Parity,” 2016).
Parity in New Jersey
The primary burden of enforcing parity falls upon each respective state. Some issues that arise include how is such consistency to be monitored and/or measured. In New Jersey, the state Department of Banking and Insurance (DOBI) is responsible for monitoring and enforcement, which currently does not require insurance carriers to file any specific documents to evidence parity compliance, (Jacobi & Ragone, 2016, p. ix). The Project also revealed that despite much public information, the data to ascertain if parity does exist with an insurance provider is not readily ascertainable by consumers, advocates and government regulators, (Jacobi & Ragone, 2016, p. viii).
For the Project, one method used to gather information was interviews of government officials, providers, health insurers, and activists to explore the public’s experiences about trying to obtain mental health services though the federal healthcare Marketplace, since passage of the ACA and MHPAEA, (Jacobi & Ragone, 2016, p. 16). The following are just a sampling of some of the matters that need to be addressed further in New Jersey. People in certain areas of the state had difficulty in finding substance abuse counselors, since many of the professionals were unable to join provider networks. A number of treatment centers proposed that Certified Alcohol and Drug Counselors (CADCs) could offer the needed services. However, at times CADCs were not compensated by insurance providers. Moreover, some southern New Jersey hospitals struggled with locating out patient treatment services after clients had completed residential substance abuse programs, (Jacobi & Ragone, 2016, p. 17).
In addition, medical professional directories provided by insurance companies were found to be inaccurate. In a survey conducted by the Mental Health Association in New Jersey, Inc., from an arbitrary selection of 525 doctors out of 702 psychiatrists listed in New Jersey based preferred provider organizations (PPOs), thirty three percent of the provider listings were not accurate, (Mental Health Association of New Jersey, 2013). Some insurance carriers commented that medical professionals do not update their contact information, and others prefer not want to participate in insurance networks. Usually, DOBI does not randomly contact providers using the contact information listed in insurance directories. However, the Department normally will investigate consumer complaints, (Jacobi & Ragone, 2016, p. 19). To help remedy the situation, DOBI now requires insurance carriers to communicate with providers who have not presented insurance claims in 12 months or greater, or contact them to confirm their intent to still belong to the provider network, (Managed Care Plans, 2016). Some advocates argue that stronger regulation is still required, (Jacobi & Ragone, 2016, p. 19).
As is demonstrated from this brief discussion, mental health parity is rather a complex issue, which requires further clarification and education especially for consumers. A regulatory infrastructure also is needed to monitor and enforce the requirements. Assistance especially for consumers does exist, such as The Sentinel Project. This can be contacted for information and/or to help consumers appeal coverage denials in New Jersey, (“The Sentinel Project”, (n.d.)). There are other resources including Parity Track, which provides mental health and substance abuse parity information on the federal government and all 50 states, including legislative, regulatory and court proceedings, (“Parity Track”, (n.d.)).
American Counseling Association (2010, March). Frequently asked questions about the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Retrieved from http://www.counseling.org/docs/public-policy-resources-reports/mental-health-parity-faqs.pdf?sfvrsn=0
Jacobi, J. V., & Ragone, T. A. (2016). Assess to behavioral health services in marketplace plans in New Jersey the puzzle of parity. Seton Hall Law Center for Health & Pharmaceutical Law & Policy, pp. viii, ix, 16, 17,19. Retrieved from http://njsentinel.org/site/images/SentinelProjectReport3draft07202016FINAL.pdf
Managed Care Plans, Provider Networks, N.J.A.C. §11:24C-4.6(d) (2016)
Mental Health Association in New Jersey, Inc. (2013). Managed care network adequacy report, p. 3.
Parity in Mental Health and Substance Abuse Disorder Benefits, 42 U.S.C. § 300gg-26(a)
Parity track. (n.d.). Retrieved from https://www.paritytrack.org/about
The puzzle of parity: Implementing behavioral health parity. (2016). Retrieved from http://law.shu.edu/events/sentinel-project.cfm
The sentinel project. (n.d.). Retrieved from http://njsentinel.org/about-us/
U.S. Department of Labor, Employee Benefits Security Administration Fact Sheet. (2010, January 29). The Mental Health Parity and Addiction Act of 2008 (MHPAEA). Washington, DC: U.S. Government Printing Office. Retrieved from https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/fsmhpaea.pdf