Why New Rules on Mental Health Are A Big Deal

Last Friday was a historic day in mental health policy. The final rules were issued for the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which was passed back in October of 2008. Consumers and mental health advocates have awaited these rules because they clarify and help reinforce provisions of the law that require mental health and substance use services to be covered the same way other health services are.

This is a big deal. Treating mental illness the same as physical illness means a lot more people will be able to get the mental health services they need without today’s red tape or outright denials from insurers standing in their way. By doing away with the artificial barrier that has been separating physical and mental health, the rules will also help reduce the stigma continuing to surround mental illness.

So what exactly do the rules, which go into effect for group and individual plans in July of 2014, do and how are they different from what came before?

• The final rules removed some confusing language currently in regulations that lets plans make distinctions between medical/surgical and mental health/substance use benefits if they meet "clinically appropriate standards of care." The Department of Health and Humans Services determined that language to be too vague, unnecessary, and subject to abuse and said there’s enough flexibility to allow for the right standards of care to be in place across the board.

• "Intermediate levels of care," such as residential treatment or intensive outpatient treatment, fall under the final rules on parity, so if health plans cover similar levels of medical/surgical care they need to do so for mental health and substance use, too.

• The expanded definition of "non-quantitative treatment limitations” means that insurance companies must provide enrollees similar access to mental health providers, based on geographic location and facility types as physical health providers.

• Final rules clarify a participant’s right to certain information, including knowing what qualifies as a medical necessity, and, if the participant is denied services, how that determination was made.

How does all this wonky talk affect someone with a mental health concern?

For those who have been denied care, these new rules will make a world of difference. (Others whose health plans were already up to the standards in these rules won’t see much of a change.) A patient may be able to receive more comprehensive, medically appropriate care for their diagnosis, even if earlier on it was denied because it was deemed too expensive by their insurance company. Many mental health and substance use treatment supports (such as rehabilitative, residential and intensive outpatient services) will have fewer superficial limits, so people can access treatment and will be able to get the right type of care for them. Additionally, health plans are being held to higher accountability standards for mental health provider access. Finally, if you are denied a mental health or substance use service, you will have more information at your disposal to determine if it was a violation of parity.

The rule definitely doesn’t answer all questions regarding an individual’s treatment needs. There are limitations to the scope of the mental health parity law and its rules. For instance, while the law’s statutory principles apply to Medicaid managed care organizations, alternative benefit plans and the Children’s Health Insurance Program (CHIP), the final rules do not. The Center for Medicaid and Medicare Services intends to issue additional guidance to help states enforce the parity law in their Medicaid programs sometime in the future.

One thing is certain, though: we are moving in the right direction. Our health care system is being shaped by policy that improves a person’s whole health – both mind and body.

Written by: Clayton Travis, Texans Care for Children. Cross-posted from State of the Children blog.