Mental and physical health are inextricably linked, yet healthcare systems have historically treated them as fundamentally different. This plays a key role in mental health stigma, but it can also make it more difficult to access mental health care.
Insurers can no longer exclude mental health conditions from coverage, or assign different copays and deductibles to mental health conditions.Federal laws have required some form of equal coverage for mental and physical health conditions—called mental health parity—since 1996. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)—which was passed in 2008 and fully enacted in 2012—toughened regulations, requiring insurers to cover mental health conditions at similar levels to the coverage they offer for physical health conditions. This means that insurers can no longer exclude mental health conditions from coverage, or assign different copays and deductibles to mental health conditions.
Legal parity certainly brings us closer to equitable access to mental health care, but it’s only a part of the picture.
Mental Health Parity Act: What it Requires
Federal mental health parity laws require most insurance plans to treat mental health conditions like physical health conditions. Parity laws for insurance coverage of mental health treatment mandate that:
- Insurers can’t require pre-authorization or a referral for mental health services if they don’t require them for physical health care.
- Insurers can’t set different deductibles, copays, or out-of-pocket maximums for mental health care.
- Insurers can’t refuse to cover a condition solely because it is a mental health condition.
- Insurers must treat mental health emergencies just like physical health emergencies, including by covering admission to psychiatric treatment facilities when necessary.
- Insurers can’t force a person to try a less expensive treatment first, if they do not require them to do this for physical health conditions.
- Insurers can’t place arbitrary limits on how long a person can stay in a psychiatric treatment facility.
Some plans, including those that existed prior to the new law, most Medicare plans, and plans that are non-compliant with the Affordable Care Act, are not covered by the newest parity laws.
Why Federal Law Doesn’t Establish True Parity
Research consistently shows that insurers violate health insurance parity laws.Research consistently shows that insurers violate health insurance parity laws. Consumers may not know these laws exist. Even when they do, enforcing them is difficult and requires extensive time and knowledge. Regulators may not fine insurers who violate the law, and the fines may be so small that they do not deter future violations.
Some common violations include:
- Refusing to pay for residential treatment.
- Requiring a referral for mental health care.
- Charging more for behavioral health medications.
- Not covering the most commonly used behavioral health medications.
- Stricter interpretation of mental health coverage requirements.
Additionally, the law does not mandate full equitable access to or coverage for mental health care. It can be more difficult for people to find quality mental health care, especially in rural areas. Clinicians may also continue to stigmatize or ignore people with mental health conditions, resulting in care delays. A 2017 study, for example, found that people experiencing mental health emergencies wait almost four times as long in emergency departments as those with physical health issues.
While mental health parity laws may mean that clinicians are more likely to get reimbursed for services, these laws can also create significant hurdles to reimbursement, and make running a practice more challenging. Some of the most prevalent issues providers face include:
- Lower reimbursement rates. A 2017 analysis found that reimbursement rates for mental health services are far lower, even when clinicians have similar training or provide similar services.
- Difficulties with health insurance panels. Getting onto a health insurance panel can be a bureaucratic challenge. This, coupled with low reimbursement rates, means that many clinicians choose not to join provider panels.
- Diagnostic and other requirements. Many insurers require that mental health providers assign a specific diagnosis prior to treating a client. When clients seek help for serious issues such as domestic violence or a recent trauma, they may not have a diagnosis. This forces clinicians to either over-diagnose or deny care.
Other Insurance Equity Challenges
Some forms of mental health parity are difficult to legislate. Mental health stigma remains a seemingly intractable problem, even though mental health diagnoses are common and treatable. Some people in need of mental health treatment may refuse to seek treatment, or believe that their need for treatment is a personal failing. Others face stigma from loved ones that can eventually cause them to abandon treatment.
It can also be difficult for clients to research mental health providers or compare methodologies. While it’s easy to assess whether a person with diabetes has appropriate blood sugar levels, it can be harder to measure how well mental health treatment is working. Clients who don’t see improvements may believe that treatment doesn’t work, not that they need to try a different treatment.
Strategies Clinicians Can Use
Mental health providers are often stuck in the gap between the coverage clients need and the coverage they have. They may have to choose between accepting lower reimbursement rates and not caring for certain clients at all. Some strategies that can help you include:
- Research provider panels, and choose to join those that offer the highest reimbursement rates.
- Offer to help clients submit their own claims. In this scenario, the client directly pays you, then submits a bill for full or partial reimbursement.
- Offer flexible payment options, such as sliding-scale fees and cash pay discounts.
- Offer alternative therapy structures. Telemental health services cost less, because you don’t have to fight traffic or even necessarily maintain a physical office. Group therapy is another alternative when you use it for the right condition, because it allows you to treat several people with related conditions at once.
- Educate clients about mental health parity laws so they know when their rights are being violated.
- Contact your state’s licensing board or professional advocacy organization. They often have specific strategies for supporting clinicians, and may be pushing local legislation to improve mental health access.
- Develop a treatment plan so clients can measure their progress. Rapid progress means a better quality of life, and may reduce total mental health spending.
- Educate clients about mental health conditions. When clients understand that mental health conditions are real and treatable, they are more likely to stick with treatment and to advocate for themselves when insurers attempt to deny their claims.
Although the dream of mental health parity is closer than ever, it is still distant from the realities of many therapy clients.
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- Barry, C. L., Huskamp, H. A., & Goldman, H. H. (2010). A political history of federal mental health and addiction insurance parity. Milbank Quarterly, 88(3), 404–433. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950754/
- Dangor, G. (2019, June 7). ‘Mental health parity’ is still an elusive goal in U.S. insurance coverage. Retrieved from https://www.npr.org/sections/health-shots/2019/06/07/730404539/mental-health-parity-is-still-an-elusive-goal-in-u-s-insurance-coverage
- Melek, S. P., Perlman, D. P., & Davenport, S. P. (2017). PDF. Addiction and mental health vs. physical health: analyzing disparities in network use and provider reimbursement rates. Retrieved from https://millimanazurecdn-test2.azureedge.net/-/media/milliman/importedfiles/uploadedfiles/insight/2017/nqtldisparityanalysis.ashx
- Mental health parity. (n.d.). Retrieved from https://www.psychiatry.org/psychiatrists/advocacy/federal-affairs/mental-health-parity
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