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Implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) has been slow, but there are small signs of progress, according to a coalition that aims to ensure that the law is properly enforced.

In conjunction with former Congressmen Patrick Kennedy and Jim Ramstad, the Parity Implementation Coalition is kicking off a series of hearings around the nation through the end of the year, to highlight problems patients are facing as they try to access addiction and mental health treatment. Speakers will also discuss where parity is increasing access to care. The first two hearings were in Michigan and Rhode Island. The next forum will take place on June 26 in Washington, D.C. Other hearings will take place in St. Paul, Chicago, Los Angeles, New York and Delray Beach, Florida. They are all open to the public.

“Anecdotally, we are hearing about increases in mental health and addiction coverage on the outpatient side,” says coalition staff member Holly Merbaum. “We also are hearing that consumers are seeing lower copays for those services.” This is an encouraging sign, since lower copays mean more people will be able to afford treatment, she adds. However, the group is hearing a number of complaints about people not getting access to residential care, partial hospitalization and intensive outpatient treatment for addiction, according to Carol McDaid, Co-Chair of the coalition.

MHPAEA is a federal law that requires insurance companies to treat mental illness and substance use disorders no differently than other medical conditions. The law applies to employer-sponsored health plans with 50 or more employees, and Medicaid managed care plans. Kennedy and Ramstad, both in recovery themselves, sponsored the legislation in the House. Kennedy’s father, the late Senator Ted Kennedy, and former Senator Pete Domenici sponsored the bill in the Senate.

Under the law, plans are not mandated to offer addiction and mental health benefits, but if they offer such benefits, they must do so in a non-discriminatory manner. That means a plan must have the same co-pays, deductibles and annual and lifetime caps on medical/surgical benefits and mental health/addiction benefits covered by the plan. Health plans cannot medically manage mental health/addiction benefits more stringently than they manage medical benefits. If out-of-network benefits are offered for medical/surgical procedures, they also must be extended to mental health/addiction services.

There is no publicly available data about how many insurers are not in compliance with the law, Merbaum says.

The federal government still has not issued a final rule to provide clarity on what employers must cover, and how parity between the medical management of medical care and mental health/addiction care applies. Some plans subject addiction and mental health benefits to a stricter form of cost containment than medical benefits, in the form of medical necessity criteria (the standards by which a health plan determines whether a particular treatment is needed), utilization review (when a health insurance company reviews a request for medical treatment), “fail first requirements” (such as requiring a patient to fail at outpatient treatment before being able to receive inpatient or residential treatment) and prior authorization for services.

There is also confusion surrounding how the law applies to Medicaid managed care plans. The government promised further guidance for states, but so far they have not issued new rules. While some states, such as New York, have issued helpful guidance on parity for Medicaid providers, many states are doing nothing to enforce the law until they receive further clarification from the federal government, Merbaum observes. “Until there’s a final rule that gives clarity to these issues, many states are taking a wait-and-see attitude,” she says. “Right now states are taking a calculated risk by doing nothing.”

“People have to fight parity fatigue,” says Merbaum. “If you see a violation of the law, you have to file a complaint. As we’ve seen with other mandates such as mammograms, they don’t enforce themselves. There needs to be a hue and cry from the affected community. Silence gives those who would like to reduce access to addiction and mental health services the excuse to continue to do that.”

Patients who want to file an appeal on a denied claim can get help from a toolkit on the group’s website, which includes instructions and sample appeals letters. Merbaum and McDaid advise people working in companies with self-insured plans to consult their human resources department to tell them about their denial of service. “HR personnel have leverage, and may be able to help,” Merbaum notes. The coalition also advises anyone filing an appeal to send a copy of the letter to their member of Congress. “We’ve seen action come from those letters,” she says.

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