Report Reveals Gaps in Coverage for Mental Health, Substance Use Disorders

By Jonathan Springston, Editor, Relias Media

A 2008 consumer protection law was designed so that insurance companies must provide proper benefits and coverage for mental health (MH) and substance use disorders (SUD). However, in a biennial report authored by several federal agencies and released this week, it appears insurance companies might not be living up to their obligations — and the government likely has been unable to enforce the rules properly until recently.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires insurance companies and group health plans to strive for “parity” when it comes to MH and SUD coverage. Prior authorization and copay requirements cannot be more restrictive than rules that apply to other services. For example, an insurance provider cannot cover nutrition counseling as part of diabetes prevention, then deny coverage for counseling on a MH disorder like anorexia nervosa.

The authors indicated there are compliance gaps, but this week’s report seems vague regarding specific examples of how insurance providers might be violating the law’s provisions. The authors were more specific about the number and types of investigations and the minutiae of how that work is performed in their report and in a separate fact sheet.

But the authors also indicated federal agencies may have lacked serious enforcement tools until recently, when Congress amended MHPAEA under the Consolidated Appropriations Act (CAA) of 2021.

“Congress provided the departments with an important new MHPAEA enforcement tool, as well as additional funding to implement it. Before the CAA, although group health plans and health insurance issuers were prohibited from imposing limits on MH/SUD coverage that did not comply with parity requirements, MHPAEA did not explicitly state how plans or issuers were to demonstrate and document that they were ensuring compliance with the rules regarding NQTLs [non-quantitative treatment limitations],” the authors wrote. “This served as a major roadblock to obtaining compliance and ensuring that individuals received the MH/SUD benefits to which they were entitled.”

Thus, this week’s report is heavy on details about these new, more robust powers and how the Biden administration moved quickly to use them, with the Employee Benefits Security Administration playing a central role. The authors explained how agencies have improved when it comes to recognizing deficiencies, notifying companies when violations occur, and remedying problems. The authors offered recommendations to ensure even stricter compliance.

Additionally, the report noted how the Department of Labor is trying to raise general awareness and alleviate stigma so more people seek MH/SUD care. "The pandemic is having a negative impact on the mental health of people in the U.S. and driving a rise in substance use. As a person in recovery, I know firsthand how important access to mental health and substance use disorder treatment is. Enforcement of this law is a top priority for the Department of Labor and an objective I take personally,” Labor Secretary Marty Walsh said in a statement.

A recent analysis from the Commonwealth Fund indicates U.S. Medicare beneficiaries were most likely to report a MH diagnosis compared to older adults in 10 other high-income countries. However, those Medicare recipients also were likely to skip seeking care because of cost concerns.

Mental Health America says 11.1% of Americans with mental illness are uninsured. Since 2011, the percentage of adults who report unmet needs in this area have increased every year, to the point that an estimated 27 million Americans are skipping needed care for mental illness.

The cover story of the upcoming March issue of ED Management is about how law enforcement officers and EMS crews often are dispatched to the scenes of behavioral health emergencies. EMS will transport these patients to the ED, where these patients might wait for hours or days to be connected to appropriate resources — or not at all. Some of these patients might go straight to jail.

At a time when resources are stretched thin, hospital staff, police officers, and communities are asking questions. In Dallas, innovators from multiple entities have fashioned a new approach to the way behavioral health emergencies are handled. The collaborative effort is producing results in terms of accelerating appropriate care to patients while also diverting significant case volumes away from EDs and the criminal justice system. Keep an eye on this space for the soon-to-be-published story.