Final rules issued this month by the Obama administration expand efforts to ensure that mental health and substance use disorders receive insurance coverage that is on par with that for medical and surgical benefits.
The rules implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) clarify interim final rules issued in 2010 and include additional consumer protections.
"This is a step in the right direction," said AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn. "I'm hopeful that we can continue to move forward."
According to the MHPAEA, plans that offer mental health and substance use disorder benefits cannot make financial requirements and treatment limitations for the benefits -- including copays, deductibles and visit limits -- more restrictive than those for medical and surgical benefits.
- elimination of an exception for certain benefits based on clinically appropriate standards of care;
- clarification that parity applies to all standards, including geographic limits and facility-type limits;
- clarification of requirements for health plan transparency; and
- clarification of a provision ensuring that parity applies to intermediate levels of care.
- HHS and other federal agencies issued final rules earlier this month that clarify and implement a law ensuring mental health services receive the same level of coverage as medical and surgical services.
- The rules go into effect Jan. 13 and apply to individual health insurance coverage for policy years that begin on or after July 1, 2014.
- More work needs to be done to eliminate the stigma associated with mental health services and disparities in how physicians are paid for providing those services.
The final rules were issued Nov. 8 by HHS and the Departments of Labor and Treasury and were published in the Federal Register on Nov. 13. The rules implementing the parity statute take effect on Jan. 13; a related technical amendment that addresses the external review process associated with a multistate plan program administered by the Office of Personnel Management goes into effect on Dec. 13.
The final rules apply to individual health insurance coverage for policy years beginning on or after July 1, 2014, according to a CMS frequently-asked-questions document.
The MHPAEA initially applied to large group plans. Mandates included in the Patient Protection and Affordable Care Act, however, draw in issuers offering small group and individual health insurance coverage and require mental health and substance use disorder coverage among the law's 10 essential health benefits categories.
"This final rule breaks down barriers that stand in the way of treatment and recovery services for millions of Americans," HHS Secretary Kathleen Sebelius said in a Nov. 8 news release(www.hhs.gov). "Building on these rules, the Affordable Care Act is expanding mental health and substance use disorder benefits and parity protections to 62 million Americans. This historic expansion will help make treatment more affordable and accessible."
The rules were finalized after a review of more than 5,400 public comments on the interim final rules.
Exemptions from the MHPAEA remain, including plans that meet requirements for an increased cost exemption, plans for state and local government employees that are self-insured, and retiree-only plans.
Even as he welcomed the final rules, Blackwelder acknowledged that more work needs to be done to eliminate the stigma of seeking and receiving mental health services and disparities in how physicians are paid for providing those services. The AAFP has a longstanding position that mental health treatments should be covered by health insurance plans in the same manner as other types of health care services.
"We don't want there to be carve-outs, especially as we're moving forward with the patient-centered medical home," Blackwelder said. "We need to be able to take full advantage of access and payment opportunities."
It's important to understand that the MHPAEA does not require all insurance plans to cover treatment for mental health and substance use disorders, and benefits vary. These factors affect how family physicians bill for services.
"If I write 'depression' on the bill, as a family physician, there are significant restrictions," Blackwelder explained. "If I write 'insomnia,' which was your main complaint but not your diagnosis, I get paid, no question."
Blackwelder said the final rules won't affect his practice because he's still left with uncertainty about whether a given patient's individual insurance covers mental health services. "It doesn't change what I do until everybody's covered," he said.
Factor in, too, the unfortunate reality that the stigma surrounding mental health issues affects how patients view their treatment, making them less likely to accept a diagnosis of depression or anxiety, for example, if their insurance doesn't provide coverage.
"Right now, we have a real issue in this country of people not accepting or recognizing mental health disorders and being understanding," Blackwelder said.
Mental health issues often manifest as physical symptoms, such as shortness of breath, chest pains and chronic bowel problems, said James Applegate, M.D., a family physician in Grand Rapids, Mich.
"Sometimes, your mental issues can be like a teapot, and if we don't find a way to relieve the pressure on the teapot, you'll explode, and you'll explode physically,” said Applegate, a former member of the AAFP's (then) Commission on Health of the Public.
The long-term and comprehensive relationship that family physicians have with their patients makes them a trusted first source for addressing the mental health issues that patients may be reluctant to accept, he said.
"There is a huge mind-body connection," said Applegate. "For the majority of mental health issues, primary care doctors and family doctors can handle those and do it well and efficiently with a patient's best interest at heart.
"Now we're going to be able to be recognized for that officially by the insurance companies."