What is this?

Often employers will ask, “What is this all about and what is the goal here?”. The easiest way to understand this is to revisit a bill previously passed in 2008 called the Mental Health Parity and Addiction Equity Act (MHPAEA).

Most plans understand these guidelines by now in that you must treat mental health and substance abuse in terms of plan benefits in same way that you treat medical and surgical benefits.  Nearly all plans at this point have corrected plan structures to accommodate for this, such as ensuring parity for deductibles and copays.

HOWEVER, the problem is that when you look at the actual OPERATIONS of the health plan things are not actually in parity.  

What does lack of parity look like?

A few examples of parity violations

This is not a comprehensive list by any means, but it will give you an idea of the type of things which can cause violations.  The below items are referencing comparing how the plan operates for Medical/Surgical benefits versus Mental Health/Substance Use Disorder 

  • All qualitative treatment limitations, plus …
  • Pre-authorization is enforced for inpatient and outpatient services.
  • Concurrent review standards
  • Determining medical necessity for services or if a treatment is investigative or experimental
  • Formulary design including which drugs are authorized and which copay tier they fall into
  • Network designs evaluating the standards for participating in the network
  • Methods for determining usual, customary and reasonable charges
  • Comparative analysis of how different providers are reimbursed for similar procedure services delivered to members
  • Comparative analysis of what percentage of Medicare is being reimbursed for claims
  • Fail-first or Step-therapy protocols
  • Any plan exclusions, including a review of denied claims for comparison purposes
  • Standards for out-of-network providers
  • Direct contracting standards
  • Restrictions for receiving care based upon geographic location, facility type or specialty
  • Differences in duration of benefits for services