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What Many Health Plans Should Provide

As a result of recent health care reforms, many health plans should be providing an array of behavioral health services, which should often include: 

This may not look like what we think of as usual care – fifty minute therapy sessions, medication management, and hospitalization if needed – but this idea of usual care does not reflect modern standards for medically-appropriate services and care coordination. What constitutes usual care should evolve now that more health plans are providing more medically-appropriate behavioral health benefits.

If you find barriers in accessing care you think you should have access to, MHA would appreciate it if you took our survey.

Some communities have some examples of medically-appropriate services and care coordination beyond traditional notions of usual care, and these are linked above. Hopefully over time, these benefits will be available in more and more communities.

Why Many Health Plans Should Be Providing This

The Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) require most health plans to cover an array of behavioral health services, and MHA looks forward to the full realization of these laws. Since the present behavioral health system in the United States is not sufficiently developed to fulfill all of these new requirements, health plan issuers, government agencies, state Medicaid administrators, providers, private sector employers, and consumers will need to work together to build out our system of care over time. For example, it will be difficult for health plans to achieve networks that are adequate enough for their subscribers have access to the necessary range of care. Though more can be made out of existing networks through the use of peer specialists and telehealth, stakeholders will still need to collaborate to build out a system that will serve everyone well and fully realize the ACA and MHPAEA.[i]

The exact requirements for health plans under the ACA and MHPAEA will vary based on the state and the plan, but the list above provides an estimate of what should be covered, based on an assumption that your state provides a reasonable package of benefits in its Essential Health Benefit(EHB) benchmark plan, and that your health plan provides a reasonable package of medical/surgical benefits for the purposes of parity. In general, the benefits listed above represent a medically-appropriate set of benefits that should be included within most medical necessity and utilization management guidelines that are reasonably calculated to meet the behavioral health needs of subscribers.[ii]

The ACA requires EHBs, including behavioral health services, to be “provided” – meaning the benefits should be offered in the normal course of usual care for providers in the network, regardless of whether a subscriber specifically requests it.[iii]

Generally speaking, MHPAEA requires that a plan not impose limitations on behavioral health treatment that are not applied equally to medical/surgical treatment. While quantitative treatment limitations are easier to understand – like a limit on the number of outpatient visits you can have in a year – parity for non-quantitative treatment limitations can be more difficult.[iv] Non-quantitative treatment limitations can arise both in the plan policy design and the application of the policy. A plan policy design can be made compliant by ensuring that non-quantitative treatment limitations apply equally across medical/surgical and behavioral health benefits. It is more challenging to ensure that the application of the policy complies with parity. Stakeholders should ask themselves, do current health plan policies and practices promote:

  • Notification to subscribers of covered behavioral health benefits that is as effective as notification of covered medical/surgical benefits?
  • Assessment during visits for behavioral health needs that is as effectively as assessment for medical/surgical needs?
  • Provision of medically-appropriate services and care coordination that meet an individual’s needs as effectively as they would for medical/surgicals need of similar severity?

In promulgating its final rule, CMS gave this example: “Example 9. (i) Facts. A plan generally covers medically appropriate treatments. The plan automatically excludes coverage for inpatient substance use disorder treatment in any setting outside of a hospital (such as a freestanding or residential treatment center). For inpatient treatment outside of a hospital for other conditions (including freestanding or residential treatment centers prescribed for mental health conditions, as well as for medical/surgical conditions), the plan will provide coverage if the prescribing physician obtains authorization from the plan that the inpatient treatment is medically appropriate for the individual, based on clinically appropriate standards of care.

“(ii) Conclusion. In this Example 9, the plan violates the rules of this paragraph (c)(4). Although the same nonquantitative treatment limitation – medical appropriateness – is applied to both mental health and substance use disorder benefits and medical/surgical benefits, the plan’s unconditional exclusion of substance use disorder treatment in any setting outside of a hospital is not comparable to the conditional exclusion of inpatient treatment outside of a hospital for other conditions.” [v]

Under the ACA and MHPAEA, health plans should now be providing a continuum of medically-appropriate behavioral health benefits, but the behavioral health care system currently lacks the capacity to ensure that everyone receives these benefits.  Stakeholders should collaborate to build out a more comprehensive behavioral health care system that can best serve everyone’s needs.

[i] 45 C.F.R. § 156.230  (“A QHP issuer must ensure that the provider network of each of its QHPs, as available to all enrollees, meets the following standards . . . Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay.”).

[ii] 45 C.F.R. § 156.125.(a)  (“Nothing in this section shall be construed to prevent an issuer from appropriately utilizing reasonable medical management techniques.”).

[iii] 45 C.F.R. § 156.115.(a)  (“Provision of EHB means that a health plan provides benefits that . . .”). See also 45 C.F.R. § 147.130. (“[A] group health plan, or a health insurance issuer offering group or individual health insurance coverage, must provide coverage for all of the following items and services . . .”).

[iv] 45 C.F.R. § 146.136.(c)(4).  (“A group health plan (or health insurance coverage) may not impose a nonquantitative treatment limitation with respect to mental health or substance use disorder benefits in any classification unless, under the terms of the plan (or health insurance coverage) as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical surgical/benefits in the classification, except to the extent that recognized clinically appropriate standards of care may permit a difference.”)

[v] Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 78 F.R. 68240, 68273 (Nov. 13, 2013), available at