Ensuring Health Plans’ Compliance With MHPAEA and the ACA

Advocates fought for five decades to secure passage of a comprehensive federal law that would require parity in coverage for behavioral health and medical-surgical services, prohibiting the benefit restrictions for behavioral health care that had been the norm. This goal was finally achieved in March 2008 with the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA), which requires plans sponsored by large employers that cover behavioral health services to cover them at parity. According to the law’s regulations, parity must be achieved with respect to both quantitative treatment limits, including outpatient visit limits, inpatient day limits, and cost-sharing requirements, and nonquantitative treatment limits (NQTLs), including utilization review and provider network management. MHPAEA offers an opportunity to expand financial access to behavioral health services for millions of Americans with private insurance coverage.

After passage of the legislation, concerns remained about how employers and health plans would respond to MHPAEA’s provisions. For example, would plans drop behavioral health benefits altogether rather than implement parity? To achieve parity, would plans reduce medical-surgical benefits rather than expand behavioral health coverage? To what extent would plans comply with provisions requiring them to remove unequal limits, including stricter management of behavioral health services?

As Horgan and colleagues report in this issue, the prevalence of behavioral health coverage remained unchanged between 2009 and 2010, the first year of MHPAEA implementation and before regulations requiring parity in NQTLs were in effect. This result is consistent with findings from a 2013 NORC study commissioned by the Assistant Secretary for Planning and Evaluation (ASPE). Horgan and colleagues also found that use of behavioral health–specific annual limits dropped almost to zero, use of prior authorization requirements declined, and the size of behavioral health provider networks increased for most plans, despite concerns that plans might shrink networks as a way to limit access under parity. Although the study by Horgan and colleagues and the NORC/ASPE study documented that a minority of plans failed to comply initially, the findings of both studies suggest that most employers and plans made substantial changes in behavioral health benefits when the law went into effect.

Now, five years later, much more has changed with respect to the financing of behavioral health services. The adoption of regulations governing MHPAEA’s implementation made a number of key changes that will affect coverage of behavioral health care, particularly the requirement of parity in NQTLs. However, the Affordable Care Act’s (ACA’s) provisions, most of which were implemented in 2014, will be just as important as the MHPAEA, if not more important, in expanding financial access to behavioral health services. Under the ACA, millions of individuals have obtained coverage for these services through Medicaid expansions, subsidies for private plans offered through the insurance exchanges, and the ACA provision that requires plans to cover children up to age 26 on their parents’ policies. The ACA extends MHPAEA parity requirements to individual and small-group plans offered through the insurance exchanges, as well as to Medicaid managed care and State Children’s Health Insurance Program plans. Importantly, the ACA mandates coverage of behavioral health services as “essential health benefits” in all plans offered through the exchanges.

Much more research is needed to understand how MHPAEA and ACA together will affect individuals who need behavioral health services. We must examine the changes that plans have made to comply with parity after final regulations were implemented in 2015, particularly changes in NQTLs that are difficult to monitor but extremely important in determining access to care, as well as the impacts of these laws on key outcomes, including utilization, financial protections for service users, and quality of care. Studying these changes is especially critical in Medicaid, which disproportionately serves individuals with behavioral health needs, and among individuals who purchase coverage through the exchanges. In addition, we need to understand how individuals who may not have been reached by MHPAEA and the ACA, including those with conditions that are sometimes excluded from coverage (such as autism and eating disorders) and those ineligible for Medicaid coverage expansions (such as undocumented immigrants) are faring after MHPAEA and ACA implementation.

Together, MHPAEA and the ACA represent a fundamental expansion in financial access to behavioral health services in this country. Horgan and colleagues provide an important starting point for what it is hoped will become a large body of research on the most important policy changes for individuals with mental and substance use disorders in 50 years.