MACPAC Notes Behavioral Healthcare Parity Compliance Challenges

Behavioral healthcare parity compliance has been complicated due to disparate strategies and data collection challenges, particularly around non-quantitative treatment limitations, a recent MACPAC brief uncovered.

The Mental Health Parity Act (MHPA) of 1996, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), and the Affordable Care Act represented three major regulatory milestones in extending coverage for mental and behavioral health.

However, MACPAC researchers found that these laws—specifically MHPAEA—did not achieve the goal of broadening access to mental and behavioral healthcare.

The researchers compared behavioral healthcare outpatient, inpatient, prescription drugs, and emergency care benefits with the same benefits medical and surgical care. 

State and managed care organization documentation informed the researchers’ efforts. They analyzed mental health, behavioral health, surgical, and medical care with respect to lifetime and annual dollar limits, financial requirements, quantitative treatment limitations, non-quantitative treatment limitations, and information availability.

MACPAC noted that the lack of progress in these areas could be attributable to the manner in which states document parity compliance. Instead of requiring broader access to mental and behavioral healthcare or specifying services that must be covered, MHPAEA targeted its efforts on certain barriers to access.

While MHPAEA successfully raised awareness about the need for greater access to care in behavioral healthcare, it did not force monumental shifts in the direction of greater access. Rather, states made minor adjustments to their behavioral healthcare coverage approach. 

Regulations around outpatient, inpatient, prescription drugs, and emergency care benefits convolute compliance efforts. Also, managed care organizations may vary regarding compliance expectations, particularly when it comes to non-quantitative treatment limitations. 

The tangle of regulations means that patients and providers may not know how to assess whether there has been a violation of parity, much less what to do if they find a violation. However, where MHPAEA was unspecific regarding behavioral healthcare benefits that should be covered, other regulations and court decisions have been clear, filling in the gaps.

Compliance and parity efforts drew from states’ and managed care organizations’ resources and time, particularly in states that contracted with managed care organizations. One state’s approach involved standardizing the process in the future to help manage changes. States and managed care organizations also adopted data collection tools.

Documenting non-quantitative treatment limitations compliance involves assessing utilization review strategies, medical necessity criteria, documented treatment plans, and network design. These elements make it a particularly challenging requirement for compliance.

Treatment system complexity hampered CMS’s and states’ non-quantitative treatment limitations data collection processes.

There was also a confusing amount of variation from state to state and stakeholder to stakeholder about how to define non-quantitative treatment limitation.

Traditionally, CMS defines this term as a policy that places non-numerical restrictions on benefits’ breadth or length. The agency has enumerated multiple examples including prescription drug formulary designs, tiered networks, and even a network’s provider reimbursement rate standards.

Differences in reimbursement strategies for behavioral healthcare benefits as opposed to medical or surgical benefits also obfuscated compliance efforts. Some medical and surgical hospital providers may be paid a fixed amount for total cost of care, whereas behavioral healthcare hospital providers are reimbursed at a per diem rate.

These issues with non-quantitative treatment limitations were not restricted to the public payer market. Commercial insurers also struggled with these policies due to a lack of partnership between insurance commissioners and Medicaid officials.

Certain states have attempted to expand the regulatory language on mental healthcare access parity. For example, California passed its Mental Health Parity Act to build on the Affordable Care Act’s advancements.

Nevertheless, behavioral healthcare parity remains low across the payer industry, particularly among regional and health plans. Over six in ten regional and state health plan executives reported that their plans saw a significant amount of out-of-network care utilization in behavioral healthcare in a recent Avalere survey.

Paying attention to out-of-network behavioral health claims, in-network reimbursement rates compared to clinical care, denial rates, and network directory accuracy can help health plans maintain behavioral healthcare parity, experts have suggested.