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The Sept. 9 release of final rules to strengthen the federal parity law for mental health and substance use benefits may have lacked the fanfare around the law’s initial signing 16 years ago, but its potential impact can’t be overstated. How these new regulations will affect treatment providers and patients will ultimately depend on how successful federal agencies and affected stakeholders are in monitoring compliance.
References to an unfulfilled “promise of parity” have become common in the treatment field. This has resulted in part from ambiguity around the scope of insurers’ obligations to offer behavioral health coverage under terms no more restrictive than those for general medical care. There also has been a lack of concrete information from insurers about the standards they have used to make coverage determinations for substance use and mental health treatment services.
The newly released regulations from the Departments of Labor, Health and Human Services and Treasury directly address these concerns. The rules will require insurers to conduct a more comprehensive analysis to ensure they aren’t being discriminatory in their use of nonquantitative treatment limitations in behavioral health, such as use of prior authorization requirements for services. The rules also mandate that health plans consider multiple factors to determine whether their behavioral health provider network is adequate, and to take corrective steps if it isn’t. The effect of nonquantitative treatment limitations on access to care has been a point of contention in several prominent lawsuits challenging insurers’ behavioral health practices.
According to an updated fact sheet from the Department of Labor, the new regulations “allow providers to obtain more information from these plans and companies about how nonquantitative treatment limitations comply with the requirements.” The document also points out that providers “can expect reasonable action as necessary from plans and companies if data, such as claims denials, in-network and out-of-network utilization rates, and provider reimbursement rates, they collect and evaluate shows material differences in access to [mental health/substance use disorder] benefits as compared to [medical/surgical] benefits.”
The regulations also clarify the parity law’s requirement that “meaningful benefits” be provided for any behavioral health condition in a classification for which general health benefits are provided. To meet this requirement, a health plan will have to offer at least one core treatment for each covered condition, the new rules state. An example of a core treatment in substance use services could be coverage of medication treatments for opioid use disorder.
Many of the rules’ provisions will take effect with new plan years starting Jan. 1, 2025, though insurers will have an extra year to implement some of the more complex standards. Some skepticism remains over whether the relevant federal agencies will have the resources to improve parity enforcement significantly. We can also expect that alleged violations of parity will continue to be fought out in the courts.
As providers of care, you too will play an important role in how parity implementation unfolds in the coming years. Seeking better information from insurers on the details of your patients’ plans, and standing as strong advocates for patients when they struggle to access needed care, can make a difference.
