Parity Remains a Work in Progress for Colorado
Total Page:16
File Type:pdf, Size:1020Kb
Parity Remains a Work in Progress for Colorado MARCH 2019 Despite more than two decades of efforts to bring parity to insurance coverage for behavioral health, many Coloradans are still not guaranteed benefits for substance use disorders that are comparable to coverage for physical health. Governor Jared Polis, elected in November, promised that his office would direct the Division of Insurance Three Takeaways (DOI) to strengthen enforcement of federal and state laws requiring parity in insurance coverage of mental • Colorado’s legislature and the U.S. Congress and physical health care. have passed a series of laws to require parity between behavioral health and physical Colorado has taken a series of steps to level the health coverage in the past 25 years. playing field over the last decade. • Two million insured Coloradans still do The state has increased access to behavioral health not have guaranteed access to covered through Medicaid expansion, added substance use behavioral health services, including disorder benefits to Medicaid, invested in integrating substance use disorder. physical and behavioral health in primary care • Offering comparable coverage for behavioral practices and elsewhere, and explored strategies to health services may seem simple, but parity reform the health care payment system. laws have proven to be complex and difficult to implement and enforce. Despite this progress on the state level and the passage of a federal parity law in 2008, an estimated 430,000 Coloradans aren’t getting the help they need overdose deaths, parity laws provide one possible for substance abuse, an increasingly common and way for the legislature to intervene. This report from often deadly behavioral health disorder.1 the Colorado Health Institute examines the advances and shortcomings of current parity laws and the As Colorado struggles with a record number of implications for substance use treatment. Federal and State Action on Parity Addiction Equity Act (MHPAEA), the most important federal law affecting substance use treatment Parity laws require insurers to provide the same level to date, required large group health plans that of benefits for behavioral health conditions as for provide substance use and mental health treatment physical health care. These benefits might include the benefits to do so at the same level as their medical number of covered visits, deductibles, copayments, and surgical care benefits.3 It required, among and lifetime and annual limits.2 other things, that payments and visit limitations for State and federal laws to promote parity have behavioral health benefits must be comparable to evolved over time. (See Figure 1.) medical and surgical benefits. In 1996, the U.S. Congress passed the Mental Health The MHPAEA was a significant step in promoting Parity Act, which required comparable annual and parity. However, it stopped short of requiring all lifetime dollar limits for mental and physical health insurers to cover behavioral health services. care. Colorado enacted its own parity law in 1997 In 2010, the Affordable Care Act (ACA) expanded (HB 97-1192), which required group health plans to parity in two ways. First, it extended MHPAEA cover treatment for six mental illnesses, including protections to insurance plans that had not been schizophrenia and major depressive disorder, at the covered under previous laws. Second, it required same level as physical illness. It did not require health individual market and fully insured small group plans plans to cover treatment for substance use disorders. to cover substance use disorder and mental health That changed in 2007, when Gov. Bill Ritter and the services as part of the law’s essential health benefits legislature updated the law to include additional package. (See Figure 1 for a timeline of these laws.) mental illnesses, such as post traumatic stress disorder, along with drug and alcohol disorders. Even with these laws, in 2019, not all insurance plans are required to cover substance use disorder and In 2008, the federal government updated and mental health services at the same level as physical expanded its parity law. The Mental Health Parity and health. The ACA did not require Medicare or self- Figure 1. Timeline of Laws Affecting Parity in Colorado 1996 1997 2007 President Bill Clinton signed the Mental Colorado Gov. Roy Romer signed Colorado Gov. Bill Ritter signed Health Parity Act, which required large HB 97-1192 into law. This law HB 07-036 into law. This law group insurance plans to not set higher required insurance companies mandated health insurance to dollar limits for mental health services to cover six biologically based cover more behavioral health if the services were offered, but did not mental disorders. Substance use services, including drug and require them to cover the services. disorders were not included. alcohol treatment, at parity. 2008 2009 2010 President George W. Bush Ritter expanded Medicaid in The Affordable Care Act (ACA) signed Mental Health Parity and Colorado to parents with incomes extended MHPAEA requirements Addiction Equity Act (MHPAEA), at or below the federal poverty level to additional types of plans and a landmark law that expanded and very low income adults without required individual market and parity and included substance use children, increasing access to small group plans to cover mental treatment. covered behavioral health services. health and substance use services. 2013 2014 Gov. John Hickenlooper signed HB13-1266 into law to Under Hickenlooper and in the wake of the Affordable align Colorado law with federal law, requiring that Care Act, Colorado again expanded Medicaid, individual, small group, and large group plans cover increasing access to behavioral health services. mental health and substance use treatment. 2 Colorado Health Institute Parity Remains a Work in Progress for Colorado MARCH 2019 Figure 2. Parity Requirements for Mental Health and Substance Use by Insurance Plan Required to Provide Parity Laws Insurance Plan Coloradans Included Behavioral Health Services Apply Medicaid/CHP+ Yes Yes 1,143,000 Individual Yes Yes 437,000 Small Group Plans Yes Yes 383,000 Fully Insured Large Yes Yes 992,000 Group Plans Self-Funded Large No Can Opt Out 1,300,000 Group Plans Medicare No No 776,000 Source: Colorado Department of Regulatory Agencies. (2018).4 funded large group plans, in which employers There are no data that show exactly how many assume direct financial responsibility for insurance people in Colorado lack equal coverage for physical claims, to cover essential health benefits. And if self- and behavioral health care. But about two in five insured plans do cover essential health benefits, they insured Coloradans have health plans that are can still opt out of MHPAEA’s parity requirement.5 exempt from the parity requirements. (See Figure 2.) State Efforts to Expand Behavioral Colorado law requires fully insured large group plans Health Care to provide coverage for behavioral health services, but self-funded plans are regulated by the federal Colorado has taken steps beyond parity requirements government and are not mandated to cover these to help people with behavioral health conditions. services. Medicare is also excluded from Colorado’s requirement. MHPAEA, the federal parity law, does In 2014, Colorado extended Medicaid eligibility to not apply to Medicare, and self-funded employer lower-income childless adults, which brought more plans can opt out of MHPAEA requirements. than 439,000 additional people into the program.6 At the same time, Colorado expanded the substance Just about a quarter of Coloradans are covered use disorder services that Medicaid covers to include by self-funded employer sponsored insurance medication assisted treatment, peer advocate plans, according to data from the Colorado Health services, and other items. It also raised the payment Access Survey and the Colorado Insurance Industry limits on services such as counseling and drug Statistical Report.7 And an estimated 776,000 screenings. Coloradans are covered by Medicare.8 Together, this is 2 million people — or 41 percent of Another large initiative, the Colorado State the total insured population in Colorado — who are Innovation Model (SIM), is a $65 million federally not guaranteed equal benefits for behavioral and funded program to help primary care providers physical health. It is worth noting that some of those integrate behavioral health services into their people likely have insurance plans that abide by practices, including substance use disorder MHPAEA requirements. treatment. These and other efforts have expanded insurance coverage for and access to behavioral An additional 350,000 Coloradans – about 6.5 health services for many Coloradans. percent of the state’s population – do not have health insurance coverage at all.8 Parity Laws Leave Many Behind Enforcement: Spotty but Improving Still, not all Coloradans have comparable coverage for their behavioral and physical health needs. Even for a state that has been advancing parity Parity Remains a Work in Progress for Colorado Colorado Health Institute 3 for decades, implementing and enforcing parity is Figure 3. Fewer Colorado Substance Use Treatment difficult in practice. Facilities Are Accepting Self-Pay Only 40% Parity laws are complicated. Even if insurers are working to follow the law, they may have a hard time determining equivalent services or enrolling enough 20% treatment providers into their networks. 34% 23% In other cases, insurance providers may say that they 0% cover behavioral health services equivalently to physical 2007 2017 health, but they may not always follow through in n Percentage of treatment facilities accepting self-pay only practice. When this is the case, the onus falls on the person 10 needing treatment to advocate for themselves to get the Source: National Survey of Substance Abuse Treatment Services. (2017) care they need. It is hard to know how often insurers are not following parity laws without clients reporting when The DOI reviews and approves hundreds of health insurers are not covering the services they need.