Disparities in Use of Out-of-Network Mental Health and Substance Use Treatment Versus Medical or Surgical Treatment

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires that health plans not apply greater limitations on in-network access to behavioral health providers than on in-network access to medical or surgical providers. In this study, we used 2021 data from the Merative MarketScan Commercial Database to evaluate privately insured individuals’ use of out-of-network providers for mental and substance use disorder treatment as compared with medical or surgical treatment.

The Merative MarketScan Commercial Database included the deidentified health insurance claims data of 22.8 million individuals with private insurance in 2021. To measure disparities in out-of-network provider use, we compared the percentage of out-of-network claims for behavioral health providers with the percentage of out-of-network claims for medical or surgical providers. We examined these disparities by care settings: acute inpatient facilities, subacute inpatient facilities, outpatient facilities, and office visits to independent practitioners (not facilities). Using the primary diagnosis on the claims, we further separated treatment by behavioral health providers into mental disorder versus substance use disorder encounters. More information on our methods can be found in a report (1).

Patients receiving care from behavioral health providers for a mental or substance use disorder more frequently saw out-of-network providers compared with those receiving care from medical or surgical providers across all four settings (Figure 1). Furthermore, out-of-network provider use was consistently higher for patients with substance use disorders compared with patients with mental disorders. For example, the percentages of out-of-network encounters in acute inpatient facilities (e.g., hospitals) were 18.1% (N=115,181 of 636,359), 4.3% (N=52,861 of 1,229,316), and 1.5% (N=1,207,062 of 80,470,788) for substance use disorder, mental disorder, and medical or surgical treatments, respectively. The percentages of out-of-network encounters in subacute inpatient facilities (e.g., residential settings) were 35.9% (N=161,414 of 449,620), 31.7% (N=39,274 of 123,893), and 1.7% (N=14,801 of 870,649) for substance use disorder, mental disorder, and medical or surgical treatments, respectively.

Our finding of greater use of out-of-network behavioral health providers versus medical or surgical providers is consistent with findings from other studies in which researchers used different methodologies (e.g., secret shopper calls, employer surveys, consumer surveys, and provider network analyses) that showed that consumers have limited access to in-network behavioral health providers (2–8). Note that the MarketScan data used in this study included only privately insured individuals; therefore, we do not know whether the results extend to individuals with Medicare or Medicaid.

Health plans have strategies to increase providers’ network participation, such as increasing reimbursement rates, reducing the administrative inconveniences of joining a health plan, and reducing the administrative burden of being paid by a health plan. In September 2024, the U.S. Departments of Labor, Health and Human Services, and the Treasury issued final regulations to strengthen the MHPAEA’s regulations to ensure network adequacy (9). Our analyses highlight the need for these regulations.