The federal government in November issued a final rule of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which spells out how the 2008 legislation is to be administered and should help eliminate inconsistent application.
An interim final rule was issued in 2010, but the final rule includes additional consumer protections, such as:
- Ensuring that parity applies to intermediate levels of care received in residential treatment or intensive outpatient settings;
- Clarifying the scope of the transparency required by health plans, including the disclosure rights of plan participants, to ensure compliance with the law;
- Clarifying that parity applies to all plan standards, including geographic limits, facility-type limits and network adequacy; and
- Eliminating the provision that allowed insurance companies to make an exception to parity requirements for certain benefits based on “clinically appropriate standards of care,” which clinical experts advised was not necessary, confusing and open to potential abuse.
“This final rule breaks down barriers that stand in the way of treatment and recovery services for millions of Americans,” said Health and Human Services Secretary Kathleen Sebelius, in a statement issued announcing the final rule. “Building on these rules, the Affordable Care Act is expanding mental health and substance use disorder benefits and parity protections to 62 million Americans. This historic expansion will help make treatment more affordable and accessible.”
Andrew Sperling, director of federal legislative advocacy for the National Alliance on Mental Illness (NAMI), says the final rule restates a number of things from the interim rule, but the most important thing it does is set forth new standards for compliance and enforcement with respect to non-quantitative treatment limits (NQTLs), such as pre-authorization rules. “The issue is not that the health plan can’t do that – it’s that if they do, they need to be applying the rules in the same way,” he says.
“These rules are a major step forward,” Sperling says.
Doug Walter, acting associate executive director for government relations for the American Psychological Association (APA) Practice Organization, was a principle negotiator in discussions between mental health and insurance advocates that led to passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Treatment Act of 2008.
“Overall we’re fairly pleased with the final rule,” Walter says. “It certainly doesn’t weaken the interim rule and it clarifies and strengthens some areas for us.”
“Our main concern has been with one of the non-quantitative treatment limitations, which has to do with provider reimbursements,” Walter says. “We have seen some really drastic reductions in reimbursement for some key services, mainly psychotherapy services, so we have spent a considerable amount of time talking with insurers to make sure they understand that you can also violate the parity law by reducing provider payments.”
Walter says the final rule does offer further guidance and clarification on reimbursement rates.
Walter is also pleased that the final rule eliminated the “clinically appropriate standard of care” exception. “We had urged that that be removed,” Walter says. “It had very little meaning as an exception, and the language ‘clinically appropriate standard of care’ is such a broad standard that it felt like a loophole.”
But while the final rule should help with compliance, Walter says there is a broader issue which is not cleared up in the final rule, and that is regarding enforcement. “The authority for enforcement falls within the federal government and we would like to know more of what they are doing and that’s not clarified in the final rule. We would like to have some more transparency in that area.”
By Pamela Berard