URAC, the accrediting body for many of the nation’s health insurance plans, has just added new accreditation standards that require health insurance plans to ensure that they are compliant with the Mental Health Parity and Addiction Equity Act. It is the first accreditation standards organization to add requirements that help health plans ensure that they do not violate the provisions of the parity law.
There have long been two different playing fields when it comes to health insurance coverage for physical and for mental health problems. Health plans had been able to establish more stringent treatment limitations for mental health benefits, such as a maximum of 20 visits per year, higher copays than for primary care visits, and more stringent utilization review criteria than for physical health care. One could have no limits to the number of primary care visits for, say, diabetes management that the plan would cover or no preauthorization requirements for management of hypertension.
This type of insurance discrimination against people with mental health and addiction problems was felt to be unfair, so Congress passed the 1996 Mental Health Parity Act to correct such behaviors. However, health plans found numerous loopholes in the original act that allowed them to continue to discriminate against people with behavioral health problems. A new law was passed in 2008 to close those loopholes.
The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans (more than 50 employees) that provide mental health and substance abuse benefits to provide them with no greater financial requirements or treatment limitations than that of their medical and surgical benefits. One of the challenges to adding teeth to this law has been the challenge in comparing health plan benefits for physical and for behavioral health. Because many plans subcontract, or carve out, their behavioral health benefits to another organization, it becomes even harder for them to ensure that the benefits provided on both sides are equivalent in nature, and that the utilization methods used to limit benefits are equivalent.
Additionally, given that enforcement of compliance with MHPAEA is split among three different government entities -- Departments of Labor, Treasury, and Health & Human Services -- it remains unclear as to who is making sure that plans are following the rules.
URAC has recently stepped up to the plate by adding parity provisions to its Health Plan accreditation standards. The new standards, which are not yet in effect, include the following requirements regarding accredited health plans:
- performance of a thorough review of federal and state laws, and regulations related to “parity of health care services,” including MHPAEA;
- performance of a detailed analysis of documenting compliance with MHPAEA (unless exempt);
- provision of a detailed analysis demonstrating that their utilization management protocols do not have more restrictive treatment limitations;
- coordination with any contracted behavioral health carve-outs to ensure that there are not more stringent quantitative and nonquantitative treatment limitations, including pharmacy services; and
- inclusion within informational documents for consumers and employer purchasers descriptions of the processes used to ensure parity act compliance, if applicable.
As part of the accreditation process, URAC will review contracts between health plans and their behavioral health carve-outs to ensure there is language that specifies how parity compliance is ensured.
These new standards are a huge step toward ensuring that the implementation of parity act requirements in health plans does not get lost among all the other health care reform activities currently underway. They also provide providers and consumers with an avenue of complaint when a plan appears to be violating these standards. The URAC website has a page for receiving complaints against accredited organizations.
<[QM]>— Steven R. Daviss, M.D., DFAPA
Dr. Daviss, co-author of Shrink Rap: Three Psychiatrists Explain Their Work, is chair of the department of psychiatry at the University of Maryland Baltimore Washington Medical Center and has served as the representative for the American Psychiatric Association on URAC’s Health Standards Committee since 2004. More information about MHPAEA can be found on mentalhealthparitywatch.org.