Our Minds Deserve Equal Care

My struggle with severe anxiety is real. I have experienced mental health crises. But I’m lucky. You may wonder why, when I’ve just admitted my mental health struggles, I would feel that way, and it comes down to privilege: While many psychiatrists and other mental health specialists don’t participate in insurance networks, leaving plenty of people with few or no options, I have been fortunate to be able to find and afford out-of-network care.

Last month, the Biden administration took bold regulatory action with a proposed rule that could begin to address this issue, improving access to mental health and substance use care for millions of Americans. While this move would dramatically enhance requirements from a 2008 landmark law known as the Mental Health Parity and Addiction Equity Act (MHPAEA), the administration should consider incorporating several Bipartisan Policy Center proposals to further close the enormous gap between the need for and access to behavioral health care.

Though I’ve been fortunate to find much needed mental health treatment, my challenge finding in-network care is not unique. In recent years, the federal government achieved only limited success in enforcing parity laws that require health plans to cover physical and behavioral health equally. Available providers are often too far away, lack timely appointments, or are simply not the right fit for patients. Because so many providers don’t accept insurance, care ends up being too expensive for many Americans, who then either defer or discontinue care. With behavioral health problems on the rise and a growing shortage of specialists, the situation is urgent.

The proposed rule takes several critical steps toward improving parity requirements. Many of the proposals align with policy recommendations made by BPC and would help others struggling with anxiety or other mental health issues receive care. The following is a breakdown of four key pieces of the administration’s rule and opportunities to include some of BPC’s recommendations.

Closing existing loopholes around parity rules 

When the MHPAEA passed in 2008, nonfederal governmental health plans (e.g., plans for state and local government employees) were not subject to parity rules. Under the proposed rule, that loophole would be closed and congressional changes to MHPAEA—specifically “requiring more than 200 additional health plans to comply with MHPAEA”—would be codified. However, the proposed rule does not specify how it would achieve this goal, so the Biden administration should consider two of BPC’s proposals. 

• In our April 2022 report, BPC recommended the Centers for Medicare and Medicaid Services (CMS) and the Department of Labor close this loophole by ensuring state and federal regulators enforce parity activities and report the steps they take. 
• We also recommended increased funding for parity enforcement of Employee Retirement Income Security Act (ERISA) plans. While additional funds may require action from Congress or budget reallocations within agencies, it would be a worthwhile investment that lowers the overall costs of patient care. 

While this may seem trivial to patients, enforcing parity rules for all eligible health plans means that fewer professionals, like the ones I see, will go out-of-network. The mental health and addiction providers covered under these plans can expect adequate reimbursements, which could mean higher salaries and better recruitment and retention. Patients in a similar situation to mine could experience significant relief in their medical expenses, particularly if their mental health providers opt to participate in their health plan’s network. 

Health plans must make necessary adjustments if they are currently not offering sufficient access to behavioral health care 

In 2020, Congress strengthened the MHPAEA by requiring health insurance plans to conduct types of comparative analyses known as nonquantitative treatment limitations (NQTLs) to assess plan compliance on behavioral health benefits. Though NQTL analyses include important aspects of managing benefits, such as prior authorizations and rate-setting methodologies, they do not have direct authority over plans that are sold to multiple employers and cannot assess civil monetary penalties.  

• The proposed rule should incorporate another BPC recommendation stating that CMS and the Labor Department monitor and enforce standards to phase out NQTLs, processes, or criteria that limit the scope of benefits provided under an insurance plan. We support the administration’s proposal to compare plans using analyses that examine outcomes of coverage rules rather than simply relying on NQTLs that provide important but limited information about plans. Ultimately, these comparative analyses will ensure people have equal medical and behavioral health coverage.  

Coupled with enforcement, these analyses will guide health plans toward ways they can—and must—improve their behavioral health benefits to comply with parity rules. By identifying and adjusting how they offer mental health and addiction care, health plans may attract more providers to their networks, and the paperwork they submit to insurance companies may be less burdensome. Patients will, in turn, have an experience that is comparable to their medical care. 

Advancing access to services in Medicare 

Currently, parity rules do not apply to Medicare beneficiaries served through fee-for-service or stand-alone Medicare Advantage plans, except through special needs plans. In our March 2021 report, we recommended expanding the law to include these beneficiaries. We support the White House’s proposal to apply parity rules to intensive outpatient services; increasing rates for crisis care, SUD treatment, and psychotherapy; and allowing more mental health and substance use providers to get paid by Medicare. The proposal would mean providers are both paid more and reimbursed for more services, which would broaden the number of patients they serve and the resources they can access. 

• BPC does, however, also urge Congress to expand the MHPAEA to cover Medicare and Medicare Advantage beneficiaries to move toward more comprehensive parity rules. 

Enhance crisis response 

In our June 2022 report, we recommended that the Labor Department, the Department of Health and Human Services (HHS), and Treasury Department clarify that behavioral health crisis response services be placed in the parity law’s emergency classification of benefits. The administration proposes improving crisis response by investing in tailored resources for underserved populations (e.g., services specifically for deaf and hard of hearing individuals).  

• In addition to these changes, the administration should also consider adopting BPC’s recommendation to require coverage of mobile crisis services and response. This would help ensure that crisis services are equivalent to emergency services (e.g., ambulance transport, emergency department care) for physical health. 

Access issues to mental health and substance use services require systemic, comprehensive reform. Implementing these parity rule updates would ensure that services are affordable and behavioral health providers are well-compensated. We celebrate the administration’s move and encourage policymakers to take further steps to help the millions of Americans seeking mental health care, like me.