Rules to require equal coverage for mental illnesses
Obama administration to issue new regulations that will define parity in treatment
WASHINGTON — The Obama administration on Friday will complete a generation-long effort to require insurers to cover care for mental health and addiction just like physical illnesses when it issues long-awaited regulations defining parity in benefits and treatment.
The rules, which will apply to almost all forms of insurance, will have far-reaching consequences for many Americans. In the White House, the regulations are also seen as critical to President Barack Obama’s program for curbing gun violence by addressing an issue on which there is bipartisan agreement: Making treatment more available to those with mental illness could reduce killings, including mass murders.
In issuing the regulations, senior officials said, the administration will have acted on all 23 executive actions that the president and Vice President Joe Biden announced early this year to reduce gun crimes after the Newtown, Conn., school massacre. In planning those actions, the administration anticipated that gun control legislation would fail in Congress as pressure from the gun lobby proved longer-lasting than the national trauma over the killings of first graders and their caretakers nearly a year ago, on Dec. 14.
“We feel actually like we’ve made a lot of progress on mental health as a result in this year, and this is kind of the big one,” said a senior administration official, one of several who described the outlines of the regulations that Kathleen Sebelius, the secretary of health and human services, will announce at a mental health conference on Friday in Atlanta with the former first lady Rosalynn Carter.
While laws and regulations dating to 1996 took initial steps in requiring insurance parity for medical and mental health, “here we’re doing full parity, and we’ve also taken steps to extend it to the people covered in the Affordable Care Act,” the senior official said. “This is kind of the final word on parity.”
With the announcement, the administration will make some news that is certain to be popular with many Americans at a time when Obama and Sebelius in particular have been on the defensive for the bungled introduction of the insurance marketplaces created under the Affordable Care Act.
According to administration officials, the rule would ensure that health plans’ co-payments, deductibles and limits on visits to health care providers are not more restrictive or less generous for mental health benefits than for medical and surgical benefits. Significantly, the regulations would clarify how parity applies to residential treatments and outpatient services, where much of the care for people with addictions or mental illnesses occurs.
Any geographic or facility-type limitations would have to be comparable for medical and mental health benefits. For example, an administration official said, an insurer “can’t say you can only get substance-abuse treatment in-state but you can go anywhere for medical/surgical.”
The officials declined to be identified speaking before the regulations’ official release.
The regulations, which specifically put into effect the 2008 Mental Health Parity and Addiction Equity Act, would affect most Americans with insurance — roughly 85 percent of the population currently, a percentage expected to rise under the Affordable Care Act — whether their policies are from employer plans, other group plans, or coverage purchased in the market for individual plans.
The final parity rules do not apply to health plans that manage care for millions of low-income people on Medicaid. However, the administration has previously issued guidance to state health officials saying that such plans should meet the parity requirements of the 2008 law.
The issue is significant because the use of managed care in Medicaid has been growing, and mental and substance abuse disorders are more common among Medicaid beneficiaries than in the general population, experts say.
The parity law does not apply to Medicare, according to Irvin L. Muszynski, a lawyer at the American Psychiatric Association.
The rules have been awaited since the 2008 law by patient advocate groups. As it happened, the groups’ complaints about regulatory delays were the subject of a Senate hearing on Thursday. Interest picked up further last month as individuals could begin enrolling in the new insurance marketplaces, or exchanges, provided under Obama’s health care law.
Treatment for mental health and substance abuse is among 10 categories of benefits considered essential and thus mandatory in plans marketed in the new exchanges to individuals and small groups. Although many insurers already provide extensive mental health coverage, some have found ways to get around existing rules and to deny payment for treatment, or to otherwise limit the benefits.
Sen. Richard Blumenthal, D-Conn., said the five-year delay in issuing a final rule had real-world consequences.
“In mental health, uncertainty kills,’’ he said. ”If an individual poses a threat to himself or others, he cannot be told he will get the care he needs as soon as his insurance company decides what ‘parity’ means.’’
Former Rep. Patrick J. Kennedy of Rhode Island, a co-sponsor of the 2008 law, said the law and the rules could be particularly helpful to veterans. “No one stands to gain more from true parity than the men and women who have served our country and now need treatment for the invisible wounds they have brought home from Iraq and Afghanistan,’’ said Kennedy, a son of former Sen. Edward M. Kennedy who has battled mental health issues himself.
Administration officials consulted closely with mental health groups in devising the rules. “What we are hearing is very positive,’’ said Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, based on what he had been told of the final language.
Under the 2008 law, treatment limits — like restrictions on the number of doctor visits or days in a hospital — cannot be more restrictive for mental health benefits than for medical and surgical benefits. But interpretation of the law left much in question.
For example, Sperling said, policyholders can easily determine whether numerical limits on doctor visits are comparable in their plans for mental and medical health care. But, he said, it is more difficult to challenge “nonquantitative limits’’ — like some insurers’ requirements that people get their authorization before seeing a psychotherapist.
The provision of the rule that will seek to clarify the amount of transparency required of health plans “is important,’’ Sperling said. Patients and their advocates say they need to be able see the criteria by which insurers find a particular service to be medically necessary, so policyholders can judge whether standards for mental health treatments are more restrictive than those for physical illnesses.
Carol A. McDaid, the leader of a coalition of patients and providers of mental health and addiction services, said: “This is the beginning, not the end, of our work to make the vision of the law a reality. We have to make sure that the law and the rules are fully enforced.’’
Insurers and business trade groups said they did not know enough about the rules to comment.
Dr. Paul Summergrad of Tufts University, president-elect of the American Psychiatric Association, said he hoped the final rules would end “the uniquely discriminatory form of prior authorization and utilization review’’ that insurers applied to emergency care for patients with mental illness.
A person who has a heart attack or pneumonia and goes to a hospital will routinely be admitted, with electronic notice sent to the insurer on the next business day, Summergrad said. By contrast, he said, if a person who is profoundly depressed and tried to commit suicide goes to a hospital, an emergency room doctor must call a toll-free telephone number, “present the case in voluminous detail and get prior authorization.’’
State insurance commissioners will apparently have the primary responsibility for seeing that commercial insurers comply with the parity standards. They already have their hands full, however, enforcing new insurance market rules, and in some states insurance regulators are considered close to the industry.
“We need enforcement,’’ Kennedy said in an interview. ”The notion of delegating this to the states, which are looking to the federal government for direction, is problematic.’’