The influence of federal parity legislation on private health plan policies: findings from a national survey

Introduction: In recent years, concern has grown about the adequacy of access to behavioral health care, and about the barriers caused by limited insurance coverage.   In 2008 the federal Mental Health Parity and Addiction Equity Act (MHPAEA) was enacted, with the goal of improving access to behavioral health treatment. The law, and subsequent regulations, prohibits commercial health plans from applying more restrictive limitations to behavioral health care than to general medical care.  The law applies not only to benefits coverage, but also to ‘non-quantitative treatment limitations’ (NQTLs) such as prior authorization.  Given health plans’ widespread use of benefit limits before MHPAEA, substantial changes were expected to result.  At the same time, there have been concerns about unintended effects of the law, for example if plans started excluding certain diagnoses, or achieving parity by reducing general medical coverage rather than by improving behavioral health coverage.

Methods: We surveyed a nationally representative sample of commercial health plans in 2014, four years after implementation of the parity law began, regarding each plan’s three best-selling insurance products.  The response rate was 80%.  We compared results to those from a similar survey in 2010 (response rate=89%), when we asked many of the same questions regarding plans’ coverage in 2010, and in 2009.  For some questions we asked plans what had changed since 2010 (before full implementation).  The goal was to assess whether parity had succeeded in improving coverage for behavioral health, and whether any of the potential unintended effects had occurred.

Results: Compared to 2010, 95% of health plan products reported having expanded the behavioral health services they covered, and 57% had reduced cost-sharing for behavioral health care.  In each case, the great majority of respondents said that the change was at least in part due to parity. By contrast, few plans reported changes to their covered services or cost-sharing for general medical care. This implies that, as intended, parity was achieved by improving behavioral health coverage rather than reducing general medical coverage.  Fewer plans excluded eating disorders than in 2010, but nearly one quarter excluded autism spectrum disorders. Nearly 40% of plans reported having relaxed their prior authorization requirements for behavioral health care, and most attributed this to parity.  Other analyses currently in progress will report on mean levels of cost-sharing for both behavioral health and general medical care.

Discussion: The results show a large number of plans improving their benefits coverage of behavioral health care, as the law intended.  Without a control group it is difficult to completely attribute this change to the law, but many respondents endorsed the law as a factor in their decisions.   Changes in plans’ managed care practices (NQTLs) are more mixed, confirming that this is a harder area to regulate successfully.   Notably, the law has not resulted in plans dropping mental health coverage or excluding more diagnoses, as some had feared.  The MHPAEA law appears to have been relatively successful in achieving several of its objectives.