It seemed like a simple concept – require insurers and health plans to provide coverage for mental health conditions to the same extent they cover medical conditions.

But experts say that mental health parity remains elusive 14 years after Congress passed a bill calling for it, even as the need for mental health services has grown during the pandemic.

The Departments of Labor, Health and Human Services, and Treasury in January issued a report concluding that insurers and health plans are “failing to deliver parity for mental health and substance-use disorders.”

“The report’s findings clearly indicate that health plans and insurance companies are falling short of providing parity … at a time when those benefits are needed like never before,” U.S. Labor Secretary Marty Walsh said in a release. “The pandemic is having a negative impact on the mental health of people in the U.S. and driving a rise in substance use.”

But insurers say that while they support parity and are working to achieve it, they are struggling with a complicated regulatory process.

Mental health parity became law in 2008 after passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). Five years later, rules governing its implementation were announced.

A plan has parity if it provides the same level of coverage for conditions such as depression or schizophrenia as it does for diabetes or another medical condition, according to the National Alliance on Mental Illness.

Among the services that must be covered equally include inpatient and outpatient in-network and out-of-network care, intensive outpatient services, partial hospitalization, residential treatment, the number of doctor visits, emergency care, prescription drugs, copays, and deductibles, NAMI reports.

But JoAnn Volk, a research professor with Georgetown University’s Center on Health Insurance Reforms, said the 2022 Report to Congress on the MHPAEA shows that insurers and plans haven’t been able to demonstrate compliance.

“The frightening conclusion of the DOL report is that health plans couldn’t even provide data to show they were doing their own robust analysis of whether they were providing parity,” she said.

“Mental health parity is a great term,” said Ken Dority, executive director of NAMI Greenville. “But in actuality, it’s not working that way for families yet.” 

Certain medications, for example, may not be included in a plan or may come with limits, Volk and Dority said. So patients may end up paying more for a medication, cut back on the dosage or not get it at all, Dority said.

“I hear that a good bit,” he said. 

Another problem is that services ordered by a provider may be deemed not medically necessary, they said. 

John Willingham, a divisional vice president with Universal Health Services, which owns about 340 behavioral health hospitals nationwide, including the Carolina Center for Behavioral Health in Greenville, said that some plans, for example, don’t cover hospitalization for opioid detox, saying it’s not medically necessary because people don’t die from withdrawal.

Some other plans don’t pay for inpatient psychiatric treatment for patients who were involuntarily committed because it doesn’t meet the criteria for medical necessity, said Anne Summer, a consultant with Mental Health Partners LLC, a company she founded 15 years ago that advocates on behalf of providers and consumers, and former owner of Palmetto Lowcountry Behavioral Health in Charleston. 

Other factors that limit reimbursement include preauthorization for care, review requirements, and stigma, she said.

“If you’re in the Emergency Department and needed to have your gall bladder taken out, there wouldn’t be any discussion about what needed to occur,” she said. “But if you’re (there) for a psychiatric condition, for some reason there’s still a discussion about what needs to occur … based on how the insurer implements the coverage.”

The mental health parity act has been a net positive, Willingham said, but it hasn’t eliminated all the problems.

Patients may have to go out-of-network to find a provider, resulting in higher costs, Dority said, noting that the number of patients going out-of-network has been rising in recent years. 

In 2013, behavioral health providers were almost three times as likely to see a patient out-of-network as a medical provider, a number that jumped to 5.2 times higher in 2017, he said.

And when it comes to substance use disorder, out-of-network inpatient facilities were used 4.7 times more than in-network facilities in 2013 and 10.1 times more in 2017, he said.

Volk and Dority said people also pay more for care when reimbursement rates for mental health services are lower than they are for typical medical visits.

And if a provider charges $150 for a service but the plan pays $35, it can take patients a long time to meet their deductible, Volk said.

In addition, care can be limited so that benefits run out before treatment is completed, Dority said – a plan may only pay for a certain number of out-of-network visits, for example.

“They’re not willing to pay long enough,” he said. “They pay enough to stabilize people, but they don’t get to work on long-term care so that patients are on the right medications and treatment plans.”

“The challenge of the law is it doesn’t say you have to (provide) good coverage,” Volk said.

So if a plan is limited in medical coverage, it can also be limited in mental health coverage, she said.

While patients can appeal an insurer’s decision about medical necessity, few do, she said, instead often giving up and paying out of pocket. There are also provisions for appealing to an external body, she said.

“But that’s a lift in and of itself,” Volk said. “They may not have the wherewithal if they’re struggling with a behavioral health condition.”

The report is the first step in a federal process of reviewing parity compliance over the coming months. It will be followed by a corrective action period during which plans can provide additional information about possible adjustments before a final determination is made.

It highlighted areas of initial noncompliance, including limits on scope and duration of treatments, telehealth, and autism services; restrictions on lab testing; and limits or exclusions on medication-assisted treatment for opioid use disorder.

One plan, for example, covered nutritional counseling for medical conditions like diabetes, but not for mental health conditions like anorexia nervosa.

The DOL’s Employee Benefits Security Administration, which has primary parity enforcement jurisdiction for about 2 million health plans covering some 136 million Americans, sent letters to 156 plans and insurers and found 48 initial parity violations among 30 of them, according to the report. Some of those plans said they intended to make changes or were already doing so.

Amendments were made to the parity law in 2021, and the January report details efforts to enforce them and report their findings for the first time, according to DOL.

David Allen, a spokesperson for the trade organization America’s Health Insurance Plans, said in a statement that insurers “are wholly supportive of parity between physical and mental health” and are working to achieve it.

“Everyone deserves access to comprehensive health care that effectively addresses their physical and mental well-being,” he said. “Since the passage of (the MHPAEA), insurers have introduced many innovations and improvements to expand access to mental health services.”

However, he said, the reporting process is new and complex and requires detailed levels of analysis in a short period of time. The report also demonstrates the need for additional help with compliance, he said.

“It’s clear that more robust tools and templates that include examples of complex benefit analyses would be useful, as would releasing de-identified examples of … violations,” he said.

“This first experience provided valuable clarification in expectations for documentation and certification,” he added, “and we look forward to continuing to work with the Tri-Departments to improve processes to demonstrate compliance with MHPAEA.”

And while the state’s largest insurer, Blue Cross Blue Shield of South Carolina, declined comment, Kris Haltmeyer, vice president of policy analysis for the Blue Cross Blue Shield Association, said in a statement that the current regulatory framework of the parity act could be improved.

“The report itself admits there’s ‘great latitude’ in what’s subject to parity, which leads to nonuniform, subjective determinations, and different standards for parity from plan-to-plan,” he said.

“We have long advocated … for the administration to provide more clarity around what constitutes compliance and better support to assist with compliance,” he added. “We are committed to complying with the law and will continue to work with the administration to provide Americans with the mental health care they need and deserve.”

Both Willingham and Summer say the focus should be on violations enforcement, noting that the Biden administration seems to be headed in that direction.

“A bill was passed in 2021 that put more teeth into the administration’s ability to enforce compliance, so there is reason for hope,” Summer said. “But it’s also a very complicated, entangled situation.”

“Parity has improved patient access to care. I’m glad we have it,” Willingham said. “We’ve just got to make sure it’s properly enforced.”

HHS Secretary Xavier Bacerra said enforcement is a top priority for the agencies, noting they’ve made improvements where they can and are using their authority to increase access to mental health and substance-use disorder care.

“We are committed to working with our federal partners to change this,” he said in a release, “and hold health plans and insurance companies accountable for delivering more comprehensive care.”

Noting that the burden of ensuring parity shouldn’t be on the provider and patient, Volk said the agencies did ask in the report for greater authority to use civil monetary penalties for noncompliance. But that will take another act of Congress, she said.

Meanwhile, families face a number of other access obstacles aside from parity, Dority said, among them the high number of private practice psychiatrists who don’t take insurance. Many people think that means they can’t be reimbursed, he said. But they can, he said, if they file with their insurers themselves, though that can pose a problem for some.  

Another barrier is the shortage of providers, he said.

“You can’t get an appointment in 30 days if you don’t have a relationship with a psychiatrist in this community,” he said. “And even if you do have an existing relationship, you may not get in in 30 days.”

Provider shortages are a problem, Volk said. But even if more providers were added, parity problems would remain unless insurers and plans change their coverage policies, she said.

“There is broad agreement there is great need out there and … growing unmet need,” she said. “At least people are paying attention now.”