A Review of State Efforts to Enforce Mental Health Parity: Lessons for Policymakers and Regulators

By JoAnn Volk, Rachel Schwab, Maanasa Kona and Emma Walsh-Alker

Executive Summary

The Mental Health Parity and Addiction Equity Act (MHPAEA) aims to remove insurance-related obstacles to mental health and substance use disorder treatment. However, federal and state regulators have found that enforcing the complex law is challenging. While insurers’ quantitative barriers to treatment such as cost-sharing or visit limits can be relatively straightforward for regulators to assess, certain “non quantitative” treatment limits, such as the use of prior authorization, provider reimbursement, and formulary design are much more difficult. Analyses of insurers’ compliance with MHPAEA have found widespread problems, from a failure to submit adequate information to regulators to clear noncompliance. These problems raise questions about the ability of plan enrollees to access critical mental health and substance use services. State insurance departments serve as the front line for MHPAEA enforcement for state-regulated individual and group-market insurance. In order to understand the challenges they face and identify potential improvements, the authors reviewed relevant laws, regulations, and guidance at the federal level and in five states: Arizona, Nebraska, Pennsylvania, Virginia, and Washington. Authors also conducted structured interviews with officials responsible for MHPAEA enforcement in these five states.

Research Findings

States’ Evaluation of Insurers’ Policies “As Written” and “In Operation” Varies Widely

State respondents are using the annual form review process to evaluate insurers’ treatment limits “as written” in their plan documents, but the level of scrutiny at this stage varies widely. They also stressed that it is important to assess how policies work “in operation,” in order to understand whether plan enrollees can access care and have it paid for under the plan’s rules. Four out of five states in our study conduct some kind of market conduct review. These can range from surveys and requests for data from insurers to full-scale, on-site market conduct exams.


The Mental Health Parity and Addiction Equity Act

MHPAEA prohibits large employer (defined in most states as employers with more than 50 employees) group plans from imposing stricter limits on mental health and substance use disorder benefits than they do on other medical benefits (referred to in MHPAEA as other medical/surgical benefits). MHPAEA does not require large group plans to provide mental health and substance use disorder benefits; instead, it requires large group plans that have chosen to cover these services to provide the benefits at parity with other medical benefits. The Affordable Care Act (ACA) expanded the reach of MHPAEA to also apply to individual and small employer group plans and requires them to provide mental health and substance use
disorder benefits. MHPAEA requires parity between mental health and substance use disorder and other
medical benefits for three different types of cost containment strategies typically deployed by insurers and health plans, each of which can impose a barrier to accessing affordable, timely care.


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