Accessing mental health treatment can be difficult, even with health insurance. Critical laws are in place to expand access to mental health treatment by requiring equal coverage of mental health and medical/surgical care. Those laws include The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Affordable Care Act (ACA), as well as resulting amendments made to the Employee Retirement Income Security Act of 1974 (ERISA).
Despite these legal developments, noncompliance with proper coverage of mental health and substance use disorder treatment under MHPAEA remains a significant issue. If you or your loved ones need mental health or substance use disorder treatment, but are struggling to access adequate care, you must understand your legal rights. In this article, we will explore Mental Health Parity in greater detail, including what it requires, which plans are subject to it, and how it is enforced.
What Is Mental Health Parity?
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that increases access to mental health and substance use disorder treatment by mandating that most health plans provide equal coverage for mental health and substance use disorder treatment as for medical/surgical treatments.
In addition to the federal Parity Act, most states, including Illinois and Washington, have passed their own mental health parity laws. Those laws vary from state to state, but may provide even greater protections than MHPAEA. For example, the Illinois mental health parity laws require that mental health treatment claims be evaluated exclusively on generally accepted standards of care. See 215 ILCS 5/370c & ILCS 5/370c.1. The Washington mental health parity laws establish an ombudsman program for mental health and substance use disorder claims to further promote access to mental health care. See RCW 71.24.045, RCW 71.24.380 & RCW 74.04.230.
Which Types of Plans Are Subject to MHPAEA?
MHPAEA applies to employer-sponsored health plans that already cover mental health services. MHPAEA does not apply to excepted benefits (such as retiree-only plans), plans sponsored by employers with 50 or fewer employees, or individual insurance plans. Importantly, the Affordable Care Act (ACA) also requires that individual and small group plans cover ten essential health benefits, including mental health and substance use disorder treatment.
What Does MHPAEA Require?
The Parity Act requires that covered health plans provide mental health and substance use disorder services in parity with the coverage offered for medical and surgical services. Importantly, it does not require health plans to cover mental health treatment or provide treatment(s) for particular mental health conditions.
For plans covering mental health services already, MHPAEA requires parity in coverage with respect to both quantitative treatment limitations (QTLs) and non-quantitative treatment limitations (NGTLs). QTLs are numerical limitations that apply to the number of visits or treatments covered under the plan or the plan’s applicable financial requirements – such as deductibles, co-pays, co-insurance, out-of-pocket treatment limitations, etc. NQTLs are anything that limit access to treatment other than numerical caps. Common examples of NQTLs include:
- Prequalification/authorization requirements;
- Formulary designs;
- Medical necessity standards;
- Step therapy protocols;
- Fail-first protocols;
- Written treatment plan requirements;
- Experimental treatment exclusions;
- Network adequacy/design; and
- Restrictions based on geographic location, facility type, and provider specialty.
Parity is also required for all levels of treatment, including inpatient care, outpatient care, office visits, emergency treatments, and prescription drugs for both in-network and out-of-network care (for plans already covering out-of-network providers).
How Is Mental Health Parity Enforced?
Group health plans are the most common benefit plan sponsored by employers today. Because MHPAEA applies to large group health plans, it amended the federal benefits law that otherwise governs all benefits provided by private sector employers called the Employee Retirement Income Security Act of 1974 (ERISA). The United States Department of Labor (DOL) is primarily responsible for regulating ERISA. The DOL is also one of the primary federal agencies tasked with enforcing MHPAEA.
Plan participants, their beneficiaries, and the DOL may use ERISA’s civil enforcement provisions to file lawsuits to enforce MHPAEA requirements under large group health plans. Even if your health plan is not subject to ERISA or MHPAEA, parity requirements may still be applied indirectly in connection with the ACA’s essential health benefits mandate. There may even be additional protections available under your state’s parity laws.
Despite these important legal developments, the DOL has reported significant noncompliance with health plans’ coverage of mental health and substance use disorder treatment under MHPAEA. That means many people have been or will be wrongfully denied medically necessary treatment.
If you or your loved ones need treatment for a mental illness, but are having difficulty accessing adequate care, critical protections are available under the law. Your health plan’s denial of medically necessary mental health or substance use disorder treatment may be illegal. Consult an experienced mental health and healthcare benefits attorney, like the attorneys at DeBofsky Law, Ltd., to understand your legal options and get the coverage you are entitled to receive.