Key Federal Departments Aim to Address Prior Authorization and Provider Network Problems

Americans face several obstacles inside the mental health financing system such as the inability to find an in-network provider accepting new clients, restrictive prior authorization systems, cost, and geographical location. Moreover, these barriers are increasing against the backdrop of the mental health and substance use disorder crisis our nation faces. As rates of mental health needs continue to rise, it is crucial that people can access mental health insurance benefits through their employers and the health insurance marketplace.

When patients seek benefits under their private health plan or coverage, they often find that coverage for treatment of mental health conditions or substance use disorders operates in a separate—and too often disparate—system than their health plan's coverage for treatment of medical and surgical conditions. These disparities exacerbate the hardships faced by people living with mental health conditions and substance use disorders.

To address these problems, Congress has passed several pieces of legislation over the last 25 years to eliminate any disparities in benefits for mental health conditions or substance use disorders that individuals would encounter when seeking coverage for the treatment of a medical condition.

Specifically, these laws and the overarching Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) have a fundamental purpose to ensure that individuals in group health plans or individual health insurance coverage who seek treatment for covered mental health conditions or substance use disorders do not face greater barriers to accessing benefits than they would face when seeking coverage for any other service.  

Key Background Materials on MHPAEA:

Parity is the basic idea that mental health and addiction care are covered by health insurers at the same level as care for other health care conditions.

MHPAEA requires parity between mental health benefits and medical benefits applying to:

• Financial Requirements, such as deductibles, copayments, and coinsurance (but the federal laws do not require parity in reimbursement rates for specific services).
• Quantitative Treatment Limitations, such as day or visit limits.
• Nonquantitative Treatment Limitations (NQTLs), which generally limit the scope or duration of benefits, such as prior authorization programs, step therapy requirements, and standards for provider admission to participate in health insurance networks.

NBCC has supported the parity laws related to financial requirements, including coinsurance, similarities between treatment limits for mental health and medical care such as the number of visits for an episode of care, and similar NQTLs such as prior authorization used by health insurers regardless of the kind of service (we are hearing reports that some health plans are beginning to eliminate prior authorization programs altogether, or many specific services).

MHPAEA parity requirements apply to group health plans sponsored by employers with more than 50 employees as well as individual health plans such as those purchased through the insurance marketplaces under the Affordable Care Act. Since final MHPAEA rules were issued in 2013, key federal agencies have continued to receive complaints that health plans have failed to comply with MHPAEA regulations by restricting access to mental health benefits especially through the application of NQTLs.

Recent Actions by the Federal Government

In late July, the three federal agencies that regulate MHPAEA—the Departments of Labor, Health & Human Services, and Treasury (federal departments)—released a new proposed rule to help improve health insurance coverage of behavioral health treatment services under private, commercial health plans for people under the age of 65. The goal is to encourage health plans to comply with mental health parity laws and regulations—especially those issued over the last decade. Finalizing many standards in these proposed rules will help end the historical inequities in access to mental health care caused by dated health plan standards. The new rule (and an accompanying technical data release) does not apply to the Medicare program and some Medicaid plans.

Requirements Related to the Mental Health Parity and Addiction Equity Act

NBCC has submitted comments on the new mental health parity requirements and the Technical Data Release.

• Comments on Mental Health Parity Rule 
• Comments on Mental Health Parity Technical Release 

In our letters to key federal departments overseeing the implementation of MHPAEA, we strongly supported the Proposed Rule’s overarching goal to increase access to mental health and substance use disorder treatment by addressing treatment limitations that place a greater burden on insureds/beneficiaries’ access to mental health treatments than to medical and surgical treatments.

We were especially supportive of the statement of the purpose of the regulations and law and the corresponding requirement that plans analyze the impact of NQTLs such as prior authorization programs on access to mental health services as part of federal government’s comparative analysis. We further supported the data collection and reporting requirements of the rule, especially with respect to the comparative analyses of NQTLs and provider network composition, as such requirements are essential to ensure compliance with the MHPAEA.

In our letters, we specifically supported several provisions, including:

• The health plan or health insurance company satisfies certain requirements related to the design and application of NQTLs.
• The health plan collects, evaluates, and considers the impact of relevant data on access to mental health benefits relative to access to medical/surgical benefits and takes reasonable action as necessary to address any material differences in access shown in the data to ensure compliance with MHPAEA.
• The federal departments’ desire to incentivize health plans to follow independent professional medical or clinical standards (consistent with generally accepted standards of care) when imposing NQTLs.
• The proposed rule would impose a special rule for NQTLs related to network composition. The proposed rule would amend existing examples and add new examples on the application of the rules for NQTLs to clarify and illustrate the protections of MHPAEA.
• The proposed rule would establish minimum standards for developing NQTL comparative analyses to assess whether an NQTL, as written and in operation, complies with MHPAEA’s requirements.
• The federal departments’ desire to require periodic independent third-party testing of provider directories to assess the accuracy of information and that a sufficient percentage of providers are accepting new patients. 

The federal departments also issued a technical release that requested public feedback on proposed data requirements for limitations related to the composition of a health plan’s or health insurance issuer’s provider network. NBCC provided separate comments on that document.

NBCC will continue to actively advocate for mental health parity for NCCs and the profession.