Many individuals with mental illness are disenfranchised from adequate healthcare coverage due to health plan restrictions. While federal parity laws try to remove some barriers, gaps remain. Select the best mental health parity.
New York’s mental health parity law helps bridge these gaps. Learn more about parity, your rights, and how you can take action—plus gain more insight into its history.
Why Parity is Important
Many individuals with mental illness face barriers to care – cost or inadequate insurance coverage are the two top reasons Americans forgo necessary treatment for mental health conditions. A recent report has confirmed this.
Parity laws have made significant strides forward by mandating that large group health plans provide parity in coverage for mental and substance use disorders, but more needs to be done. State and federal lawmakers must expand mental health parity by enforcing existing laws and mandating it across all forms of insurance, including individual plans, small group plans, Medicaid managed care organizations (MCOs), Medicare fee-for-service and Medicare Advantage coverage, and private employer group coverage such as VA benefits or children’s health insurance programs.
To address these challenges, the Kennedy Forum has designed a comprehensive set of tools to aid consumers, providers, and advocates in understanding mental health parity and advocating for its enforcement. Our website features information about state and national laws as well as their enforcement; tips for filing complaints about treatment limitations, both quantitative and nonquantitative; an explanation of these differences as well as links to resources offering more education on mental health parity;
One reason that more needs to be done in terms of mental health parity laws and enforcement is that they don’t guarantee coverage for those suffering from covered disorders. According to the Congressional Budget Office’s recent analysis, even after expanding MHPAEA coverage to include individual and small group markets through Obamacare, many individuals and families still struggle with limitations placed upon their MH/SUD benefits.
Department of Labor (DOL) has initiated active enforcement of mental health parity. In August of 2021, DOL filed its inaugural federal lawsuit to enforce parity — Walsh v. United Behavioral Health — against a large group health plan for violating the Mental Health Parity Act by setting limits that were less favorable than any such limits imposed on medical/surgical coverage and using non-qualifying threshold levels such as financial requirements, utilization review criteria, fail-first policies and coding/claims processing procedures to restrict access to mental health services.
Getting Started
The federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA, or “parity law”) mandates that most group health plans and insurance issuers treat mental illness and addiction coverage as equal to medical/surgical benefits in terms of financial requirements such as deductibles, copays, or out-of-pocket limits imposed upon MH/SUD benefits in their plans. Furthermore, any cumulative financial requirements placed upon mental illness/addiction benefits should not be more restrictive than equivalent requirements placed upon medical/surgical benefits in their plans.
Parity laws and rules mandate that health plans provide comparable levels of benefits yet do not guarantee people will access adequate mental health care. Many may still struggle to find adequate, affordable, and accessible treatment providers in their locality, and certain forms of insurance do not need to abide by parity rules, such as Medicare Fee-for-Service plans and Veteran Administration health plans, in addition to short-term limited duration health plans.
Thankfully, several states have passed laws that go beyond the minimum requirements under MHPAEA and can assist consumers in upholding their rights under federal parity law. New York State passed such legislation in 2018, mandating formal parity compliance plans, regular reporting to state officials, and additional enforcement mechanisms.
Even where state parity laws exist, federal parity law takes precedence when they conflict. Furthermore, the Affordable Care Act extended these protections to individual and small-group health plans as well as employer-sponsored group plans covered by MHPAEA.
As a result, federal parity rules now cover far more people who had access to mental health and substance use disorder treatment coverage before. While this is undoubtedly positive news, we must continue our fight for parity while expanding access to high-quality care services.
AFSP has created several resources to assist individuals and families in understanding how the parity law works and their rights under it, such as the “Know Your Rights: Parity for Behavioral Health” pamphlet and an online guide that provides an overview of mental health parity laws with a list of rights associated with them. Furthermore, AFSP is working towards improving the enforcement of said laws as well as consumer tools available for upholding them.
Appeals
Parity laws aim to provide people living with mental health and substance use disorders (MH/SUD) access to equal care; however, barriers remain. Finding an in-network provider may be challenging, and insurance premiums and co-pays can make treatment unaffordable; additionally, many MH/SUD patients are denied coverage or have their claims rejected by health plans; any denial is an act against parity laws, which should be appealed immediately.
For consumers to safeguard the rights of those covered by parity laws, they must be informed about their rights and understand how to appeal a decision. Learning more about parity laws will enable consumers, family members, and advocates to advocate on their behalf and get them the treatment they need.
Federal and state parity laws currently cover most employer-sponsored group health plans (i.e., those typically offered by businesses). However, these do not cover all health expenses; many plans provide benefits such as hospital stays, doctor visits, prescription drugs, or other services that fall outside its purview (MHPA). Furthermore, many state and local government employees are covered by plans not subject to its application (for instance, state employee plans that do not fall within its purview).
Some groups have urged policymakers to extend a parity law to these plans. Current state statutes in Arizona, Colorado, Indiana, South Carolina, Vermont, and Wyoming contain provisions that extend the law to some of these plans.
Concerns have also been expressed in regard to expanding parity laws to these plans, with some analysts noting that doing so may result in cuts to health coverage for other workers. If companies must allocate part of their fixed health budget towards mental health benefits, such as EAP coverage, this may necessitate either decreasing other coverage or completely discontinuing it altogether.
However, The Kennedy Forum strongly believes that passing parity laws for these plans is an integral step toward improving access to treatment. Therefore, the Kennedy Forum and other stakeholders must closely monitor progress toward enforcement and strive towards their full implementation.
Resources
Even with the progress made through federal parity laws, mental health and substance use disorders continue to experience less generous insurance coverage than medical or surgical conditions due to cost-sharing (deductibles, copayments, and coinsurance), treatment limits such as day/visit limitations as well as non-quantitative limits (such as step therapy and prior authorization) or coverage barriers such as daycare costs that significantly outstrip medical/surgical services costs. Furthermore, mental healthcare costs significantly more than its medical/surgical counterparts.
Various resources are available to assist you in advocating for parity. State and national advocacy coalitions, as well as local organizations, offer assistance; for example, in New York State, the Kennedy Forum and NYSPA’s Parity Appeals Program (CHAMP) can assist with complaints or appeals against insurers for failing to meet parity requirements.
As a member, you can also join your state association and local chapter to work toward improving policies on this issue. Many chapters offer voluntary leadership positions for parity liaisons that can serve as valuable resources in identifying issues and opportunities in your area. You may also work directly with legislators by reaching out directly and encouraging those with personal ties to BH to promote improvements to parity laws in their state.
Consumers may understand that the federal parity law applies to their health plans, yet they may lack knowledge on how to recognize and enforce violations. To provide clear instructions for the identification and enforcement of violations, The American Psychiatric Association has designed an educational poster in English and Spanish to inform patients of their rights as individuals and help them seek fair insurance coverage. Furthermore, people should know they can file an appeal if they believe their insurance company has broken any of its policies.
For information on filing a parity appeal, consult the Kennedy Forum’s Guide to Parity Appeals. Additionally, they offer several resources that support mental health advocates who wish to file parity appeals, especially their toolkit, which addresses some of the most frequently experienced difficulties during this process.
