Ask the doctor: How does health care reform affect mental health parity?

Published: July, 2010

Q. How will national health care reform affect my mental health coverage? Does this new law nullify the parity bill that was supposed to take effect in 2010?

A. Many patients are asking the same question — and for good reason. The health care legislation signed into law earlier this year by President Barack Obama is complicated, with different provisions that are phased in gradually. Professional societies and patient advocacy groups are still analyzing the details.

First it may be helpful to review where things stand with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. This law affects large employers (those with at least 50 employees), Medicaid managed care plans, and some State Children's Health Insurance Program plans. Generally speaking, the mental health parity law requires that insurers cover psychiatric disorders on a par with other medical disorders. This means that out-of-pocket expenses and duration of treatment must be the same for all medical problems, including those considered mental or psychiatric disorders. In late January 2010, the three federal agencies in charge of enforcing the law issued detailed regulations concerning its implementation. These rules take effect as of July 1, 2010.

In March, President Obama signed two separate health care reform bills into law: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. Together, these bills are meant to expand health insurance coverage, control health care costs, and improve systems of care. The legislation does not trump the Wellstone-Domenici mental health parity law, but rather extends its benefits to more people.

Probably the biggest impact will be felt by the millions of Americans who currently lack health insurance — among them people who are self-employed, who work for small employers that don't offer policies, or who have pre-existing conditions (including psychiatric disorders) that in the past were cited by insurers as justification to deny coverage. Under health care reform, individuals now may be eligible for Medicaid or be able to purchase health policies through state-based exchanges. Notably, any of the policies offered through Medicaid or through the exchanges must offer mental health and substance abuse treatment services as part of their "essential benefits" package (the minimum required under the law).

Medicaid eligibility is expanding to include more low-income patients with psychiatric disorders. Until now, the only way that many adults with psychiatric disorders could qualify for Medicaid was to first obtain Supplemental Security Income disability payments — and some people either didn't apply or didn't qualify. In addition, the new law for the first time lists a serious mental illness as one of the qualifying chronic conditions for a "medical home" (a way of coordinating care) under Medicaid.

People who wish to purchase health insurance on their own will be able to choose from plans offered through state-based exchanges. Participating health insurers will be required to offer policies to everyone who applies, and cannot refuse coverage on the basis of pre-existing medical conditions, including mental health or substance abuse disorders. The new law also requires these policies to comply with all provisions of the Wellstone-Domenici mental health parity law.

In addition, the health care reform law sets aside funds to invest in education and training for mental health and behavioral clinicians. It also provides more money for research and patient education.

Given the new law's complexity and scope, it will likely take years to fully understand how these provisions will actually be interpreted. Successful implementation will require the work of many people of vision and good will. There is no doubt, however, that the new law represents a significant advance in the efforts to insure more people.

— Michael Craig Miller, M.D.
Editor in Chief, Harvard Mental Health Letter

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