Where are we with parity?

This month marks the anniversary of the Wellstone and Domenici Mental Health Parity and Addiction Equity Act  (MHPAEA) Mental, signed into law on October 3, 2008. Behavioral health care providers welcomed this legislation. Group health plans that cover mental illness and substance use disorders must now provide those benefits at the same level as medical and surgical benefits.

While MHPAEA was intended to eliminate unequal coverage and inequities in access to behavioral health treatment, providers and their patients continue to face challenges in making sure the law is fully understood and implemented.

Patrick Gauthier, Director of AHP Healthcare Solutions, addressed these issues in a recent presentation for NIATx, “Parity & Equity Compliance Checker: Disputing the Decisions that Affect Your Bottom Line.”   Gauthier describes his presentation as a three-step approach to parity and equity compliance: Determine, Detect, and Demand.

1.Determine when parity applies. Many believe that the parity and equity act mandates that all insurers cover mental health and substance use disorder services. In fact, the law applies only to insurers who choose to cover those services, and then only to certain plan types.

When checking benefits at admission, providers need to determine whether a patient’s coverage and plan type comply with the law. They also need to check the annual and lifetime maximum benefit across all medical coverage, whether or not there is a separate behavioral health deductible, along with other variables such as copays.       

Providers also need to be aware that–until the federal government provides other guidance –the law allows each state to define the “scope of service”: what conditions, services, and provider types are covered. Gauthier offered the state of Illinois as an example, where the definition of inpatient treatment includes residential/sub acute inpatient treatment–allowing for parity in coverage.

2.Detect problems. The presentation included a sample tracking form, the  “Parity & Equity Coverage: Compliance Tool” that’s designed to help providers determine a plan’s compliance with the MHPAEA.

3.Demand that problems be corrected. Be prepared to notify your state insurance commissioner when a payer denies coverage or does not offer an equitable scope of service. Collaborate with the state provider association or other advocacy group to blow the whistle on a payer that is clearly not in compliance with the law. Effectively remediating issues will require attention to detail and documentation, so make sure you’re collecting information by using a form like the “Parity & Equity Coverage Compliance Tool.”

The second half of the presentation covers the most common reasons for denials and the process for appealing them. Gauthier encourages providers to be persistent: claims denials can represent as much as 15 to 20% of a provider’s revenue, and patients and providers win more than 50% of appeals.

Gauthier concludes: “MHPAEA was and continues to be an important victory for all Americans. It’s as much a civil rights success story as it is an insurance reform. Viewed in relation to the Affordable Care Act and Essential Health Benefits, applied in the context of Medicaid expansion and health insurance exchanges, MHPAEA is our gold standard for behavioral health benefits. Therefore, we should all be actively involved in its implementation and enforcement. That work must happen at the state and community levels.”