The concept of behavioral health (BH) parity has been enshrined in federal law for nearly 30 years. Monitoring payer compliance with it, however, has been a challenge for about as long. But recent updates to BH parity legislation—on the heels of a high-profile lawsuit against a major health plan—may improve enforcement of parity rules. 这可能会对支付者、患者和提供者产生重大影响.
我们是如何来到这里的
BH parity rules mandate that insurance coverage for mental health and substance use disorder services should be equal to that for physical health services. BH parity was first memorialized in federal legislation through the 1996 Mental Health Parity Act, but it was the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) that expanded the 1996 law and closed loopholes in it. 其核心是, MHPAEA aims to prohibit coverage limitations that are more restrictive to BH benefits than to traditional physical health/medical benefits.
While benefit parity tends to be the most heavily discussed component of BH parity, 嵌入平等立法是额外的, 同样重要的是 需求 用于供应商网络管理,患者访问和报销.
1. 纳税人 are accountable for developing adequate BH provider networks to increase access to care for patients.
保持符合MHPAEA, the methods used by payers to evaluate the size and composition of provider networks must be applied equally to BH and physical health services. 例如, if a payer implements measures to grow their primary care network to reduce wait times, they would be required to evaluate wait times for BH services and apply similar measures to expand their BH provider network. 另外, standards and time frames for BH contracting and credentialing must be comparable to those of the physical health network.
Parity in network adequacy standards does appear to have had a positive impact in increasing network size. A 2022年行业调查 by American Health Insurance Plans (AHIP) found that commercial health plans increased the number of in-network BH providers by an average of 48% in three years. 虽然这份报告令人鼓舞, 提供程序属性的一个更细微的视图——许可证类型, 位置, 性别, 语言, 文化, 等.—is needed to determine how well the provider network fits the member population’s needs.
2. 提供者有权获得相应的补偿.
While MHPAEA does not require equal reimbursement for BH and physical health providers, 付款人确定报销的方法必须相同. 例如, if physical health providers are paid 5% more in a high cost-of-living area to ensure network adequacy, BH供应商必须获得相同的保费.
Reimbursement parity goes a step further in some states that require commercial healthcare payers to set 高级执业提供者的报销率 (nurse practitioners and physician assistants) equal to those of physician-level providers for the same services. 尽管许可证级别的报销平价与MHPAEA无关, the state legislation in conjunction with the MHPAEA encourages market-commensurate compensation for advanced practice BH providers.
展望未来:更有影响力的立法
到目前为止, the impact of parity legislation on BH treatment access and provider network quality has been mixed. 不可否认,获得医疗云顶集团的机会有所改善, 最终, the provisions of MHPAEA have proved burdensome for payers to operationalize and, 由于一些要求的主观性, 监管机构难以监督和执行.
到2021年, 对联合医疗的诉讼 found the methodology used to determine out-of-network reimbursement did not align with parity 需求, prompting rate adjustments for both out-of-network and in-network providers in multiple states. While it is unfortunate that identifying and rectifying a parity violation required a lengthy federal and state investigation, it is encouraging to see a positive outcome resulting from enforcement of MHPAEA.
在这种势头的基础上, MHPAEA的更新于2023年提出 that are intended to further refine and clarify key provisions around parity 需求 for network management. The proposed rules outline metrics for network composition in four areas that will help to objectively identify deficits in provider networks, 以及检测潜在的MHPAEA违规行为;
- 网外的利用率: Geographic areas with disproportionately high out-of-network utilization could indicate an insufficient network of contracted providers.
- 网络内供应商主动提交索赔的百分比: Discrepancies between the number of providers published in the network directory and the number of providers actively submitting claims could be indicative of a “ghost network” that cannot support demand.
- 时间和距离标准: Measuring the time and distance members must travel to access care is an important indicator of true access and availability. This standard has been utilized by Medicare Advantage plans to measure network adequacy for many years.
- 还款利率: Discrepancies in reimbursement between BH and physical health providers (using Medicare as the benchmark) could indicate disparate reimbursement levels.
如果最终确定, these updates to MHPAEA will hold payers accountable by measuring network size based on active providers, 监控网络内与网络外利用率的比率, 评估补偿以确保同等. 虽然拟议更新背后的概念并不新鲜, the advancement of methods to monitor compliance with parity 最终 serves to protect patients’ rights, as well as advance the progress we have made toward equitable access to BH services over the past three decades.
五月是心理健康宣传月, 整个月我们都会分享行为健康领域的观点.
马特·马斯林编辑
出版于2024年5月7日