Mental Health Parity – Filling in the gaps

Believe it or not, there is a silver lining within the Patient Protection and Affordable Care Act for Behavioral Health Providers. In short, the Act does what the Mental Health Parity Act and the Paul Wellstone and Pete Domenici Mental Health Parity Act of 2008 attempted to do but fell short of doing. The original Mental Health Parity Act (MHPA) was signed into law in 1996. It prohibited annual and lifetime limits on mental health benefits under employer group health plans to the extent they were more restrictive than limits on physical medicine benefits. In 2008, the MHPA was amended by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (Wellstone Act). The Wellstone Act prohibits employers from differentiating between mental, substance abuse and physical benefits in their group health plans with respect to deductibles, copays, coinsurance and treatment limits. The Department of Health and Human Services issued regulations in February of 2010 which clarified the prohibitions within the Wellstone Act. One would think that the MHPA and Wellstone Act resulted in a level playing field between mental and physical health benefits under employer group health plans. Unfortunately, the MHPA and Wellstone Act have become more about the exemptions than equalization of benefits. First, employers with fewer than 50 employees are exempt from the MHPA and Wellstone Act. In addition, any employer may claim an exemption based on the fact that compliance with the provisions of the MHPA and Wellstone Act would significantly increase the cost of its health plan. While the Wellstone Act went one step further in requiring actuarial certification of the cost based exemption, it did not eliminate the largest hole in achieving mental health parity. It did not require behavioral health benefits be offered as a part of any employer group health plan offering physical medicine benefits. The two laws only require equality in plans where behavioral health benefits are offered. The gaping hole in achieving true parity of mental health benefits appears for the time being to have been plugged under the Patient Protection and Affordable Care Act. One of the central planks of health insurance reform within the PPACA is the concept of “essential health benefits.” Health care issuers that offer coverage in the individual or small group market are now required to offer “essential health benefits” as defined in Section 1302 of the PPACA. In addition, the employer fines and penalties which serve as another central plank under the PPACA are not as great for employers offering essential health benefits to their employees. While the complete definition of essential health benefits is being left for the regulatory process, the Secretary of Health and Human Services is mandated under section 1302(b) of the PPACA to include at least the following “general categories and the items and services covered within the categories: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care.” The required inclusion of mental health and substance use disorder services, including behavioral health treatment within the definition of “essential health benefits” will do more to establish true mental health parity than the prior attempts within the MHPA and the Wellstone Act. Now, it is incumbent upon all in the Behavioral Health industry to ramp up and prepare for the increased assess to Behavioral Health services among private insurance enrollees. One can only speculate how a system built primarily to serve the uninsured and underinsured populations will evolve based on the increased demands within the existing system.

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