If ending behavioral health discrimination were a race, it would surely be a marathon. One step at a time, progress has been made to ensure that treatment for mental health and substance use disorders is covered at parity, or equally to other forms of medical treatment under health insurance plans. As we reported last week, these wins are not yet enough to guarantee equality. The odds are still stacked against consumers with behavioral health needs.

But we moved one huge stride closer to the finish line when the federal government released a proposed regulation earlier this month spelling out how mental health and substance use disorders parity standards apply to Medicaid and the Children’s Health Insurance Plan (CHIP).

The new regulation to implement the 7-year-old Mental Health Parity and Addiction Equity Act will help an estimated 21 million Medicaid beneficiaries and 850,000 CHIP beneficiaries get better access to care.

The parity regulation, when finalized, will apply to CHIP, all versions of Medicaid managed care and partially to alternative benefit plans (ABP) in Medicaid expansion, and will protect consumers who are enrolled in those programs.

With the stakes so high, let’s look at the highlights of the proposed regulation:

  • All mental health and substance use disorders benefits offered through Medicaid managed care organizations (MCOs) are subject to parity requirements, regardless of how the services are delivered. This means if a Medicaid MCO contracts these benefits to a behavioral health management company, the overall plan is still responsible for ensuring services comply with parity.
  • Copayments, deductibles and any limits on the number of visits or length of treatment cannot be more restrictive for behavioral health services than those applied to most medical/surgical benefits.
  • Other health plan rules, policies or practices that cannot be measured by a dollar figure or number, such as prior authorization, also must meet the parity standard.
  • Plans must be more transparent about their policies. Medical necessity determination criteria for substance use and mental health benefits must be made available and plans must provide explanations when services are denied.
  • All CHIP services, regardless of whether delivered through managed care or fee-for-service must comply with parity.

For the policy wonks in the audience, check out Tim Jost’s blog on Health Affairs for a more in-depth rundown of what the proposed parity regulation covers.

With so much good news to celebrate, one might wonder whether we’re sprinting toward the parity marathon finish line with fists raised in victory. Of course, this race won’t be won so easily.

Here are just a few roadblocks that still stand in the way:

  • We are likely looking at two years or more before Medicaid enrollees will see the full benefits of this parity regulation. In addition to a comment period, the final rule will not go into effect until 18 months after it is finalized.
  • Enforcement must be stepped up. We are heartened to see that the proposed regulation outlines consequences including the possible withholding of federal Medicaid matching funds for states that aren’t in compliance with parity rules. But greater analysis of outcomes for behavioral health consumers on the ground is needed, including better data collection and reporting of consumer parity complaints with state agencies. As we’ve seen in private insurance, parity is not guaranteed by laws and regulations alone—how rigorously these laws are enforced contributes to their efficacy in ending behavioral health discrimination.
  • The parity regulation does not change the fact that the Mental Health Parity and Addiction Equity Act by design excludes fee-for-service Medicaid and all of Medicare. Behavioral health equity will not be complete until these programs are subject to the same standards as private insurance and Medicaid managed care.

The comment period for the proposed regulation is open through June 9. Community Catalyst will be submitting comments in response to the proposed rule. We will also provide template comments for state advocates who are interested in weighing in – stay tuned!

This week, Montana becomes the 29th state (plus the District of Columbia) to close the coverage gap, and the first state to get legislative approval to expand Medicaid in over a year. As a result, 70,000 low-income Montanans will soon gain health coverage, many for the first time.

This was not an easy fight. The bipartisan compromise passed through both Republican-controlled chambers this month despite the best efforts of well-funded conservative political organizations like Americans for Prosperity (AFP) and the state’s Tea Party-affiliated House leadership.

How did people prevail over politics? There are a lot of reasons, but top among them is smart, sustained, authentic community organizing.

Under the leadership of Montana Women Vote and the Montana Human Rights Network among others, a coalition of advocates had been conducting public education events and canvassing in key districts on this issue since 2013. Over the years, they built a list of thousands of volunteers who were educated and actively engaged, they trained dozens of Montanans who were trapped in the coverage gap to lift up their voices, and they engaged countless hospitals, businesses, and even city council-members in target areas.

Because of this solid groundwork, the campaign was able to generate a firestorm of support for closing the coverage gap in the weeks leading up to the final votes, including over 11,000 calls to legislators and an average of 8-10 earned media pieces a week.

By contrast, AFP did not invest time building relationships in affected communities on this issue. Instead, they invested hundreds of thousands of dollars, and assumed that would buy them the influence they needed. But they were wrong.

AFP and other conservative political organizations relied on expensive paid ads, push-polls and mailers in the weeks leading up to the vote to generate opposition to closing the coverage gap. But without pre-existing relationships on the ground, these efforts generated only 755 calls to legislators during the week of the key votes; during that same week, supporters generated nearly 6,000. And when AFP organized “town hall” events to target three Republican legislators who were considering supporting the bill, Montana citizens who supported closing the coverage gap turned out in such high numbers that AFP was forced to apologize for its tactics.

The recent success in Montana is a win for low-income Montanans, and it’s a refreshing reminder that sustained, strategic and organized consumer advocacy can triumph over moneyed interests.

Yesterday, we alerted our partners to the great news that the Senate had passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In addition to permanently repealing the Sustainable Growth Rate, the flawed formula used to determine Medicare physician payment rates, we are pleased that MACRA refunds the Children’s Health Insurance Program (CHIP) for two years with all its current provisions intact. It also provides funds for community health centers, the Maternal Infant Early Childhood Home Visiting program, and family-to-family information centers and continues the Transitional Medical Assistance program which supports families as they transition out of Medicaid eligibility.

In reflecting on this huge win for children and families, we want to thank our partners for their tireless advocacy for CHIP. These advocates encouraged their governors to submit comments about the importance of CHIP in their state, educated their Congressional delegations about the harm that would come from losing CHIP funding, and activated their grassroots to ensure policymakers heard the message loud and clear. Their engagement on the issue of CHIP funding has been unflagging, and we are deeply appreciative of their work—we hope they will take a moment out of their busy schedules to take a victory lap!

So what’s next for children’s health? We still have plenty of work to do, ensuring that kids who enroll in Marketplace plans—now or in the future—have access to comprehensive benefits and provider networks via policies that are affordable for their families. We need to continue exploring policies that will support continuity of coverage and reduce churn, so kids can stay connected to the care they need. And we are excited to think about health system transformation with an eye toward children’s health, building on our existing work on children’s health care quality. We are looking forward to engaging with our partners on all these topics and more. 

Imagine you have diabetes and your insurer won’t pay for insulin. Instead, you have to pay out of pocket or face blindness, or even death? Now imagine you learn that people like you with diabetes were twice as likely to be denied treatment compared to people with other medical problems. Sound unfair to you?

For millions of people who need treatment for drug and alcohol problems or mental illness, inequity is a reality.

Behavioral health discrimination in health insurance is once again in the spotlight. Health insurance denials for substance use and mental health care in private insurance plans were nearly twice those for other medical care in the last year, according to a report released last week by the National Alliance on Mental Illness (NAMI). NAMI is one of our partners advocating for more fair treatment for people living with chronic behavioral health problems.

For years, people with behavioral health issues, their loved ones and advocates have pushed for a more equitable system, one in which substance use and mental health treatment is covered equally, or at parity with, other forms of medical treatment under health insurance plans. This work resulted in the 2008 passage of the Mental Health Parity and Addiction Equity Act, a federal law requiring many health insurance plans to follow parity rules, meaning that if they offer mental health and substance use disorders benefits, they must cover them equally to other medical benefits. The Affordable Care Act (ACA) has extended these protections to more health plans. New federal regulations were issued in late 2013 for private plans and proposed regulations came out last week for Medicaid.

NAMI surveyed nearly 3,000 behavioral health consumers (thanks to those of you who participated!) and analyzed 84 insurance plans in 15 states. The takeaway? While more consumers than ever should have access to health plans that require behavioral health parity as a result of the ACA and the federal parity law, consumers are often left without the treatment they so desperately need.

In addition to the high rate of substance use and mental health coverage denials, the survey’s highlight other common problems with parity implementation:

  • Many insurance networks have far too few substance use and mental health providers
  • Discriminatory drug tiering, when insurance companies make medication for certain conditions more costly for the consumer, creates barriers to needed for substance use and mental health disorders
  • Consumers do not have enough information about behavioral health coverage to compare health plans and choose a health plan that meets their needs

What can we do?

If you’re looking for even more ideas, you’re in luck! Keep your eye out for new Community Catalyst resources on behavioral health parity enforcement in the coming months. It’s time to leverage the letter of the law to make behavioral health equity a reality in our health system. Together we can make change – let’s work to keep the spotlight on parity.  

We know we’re starting to sound like a broken record, but we couldn’t help but share that yet another report boasts how closing the gap is good for state budgets. It’s no surprise—similar to the outcomes we highlighted in previous posts, this most recent study from the Robert Wood Johnson Foundation and Manatt Health Solutions finds that closing the gap will deliver more than $1.8 billion in savings and new revenues for eight states by the end of 2015.

These savings and revenues come from three key sources:

  • Savings from enhanced federal matching. States that have closed the gap receive 100 percent federal funding for providing full Medicaid coverage to beneficiaries who previously had limited Medicaid benefits. These folks include “medically needy” individuals, pregnant women and individuals with disabilities. Seven out of the eight states in this study projected savings in this category.
  • Reduced state spending on programs for the uninsured. Now that certain groups of people are no longer in the coverage gap and are able to secure full Medicaid benefits, every expansion state will spend much less on state-funded health care for prisoners, mental and behavioral health programs, public health programs and uncompensated care funding to hospitals.
  • Increased revenue from insurer taxes. Four states in the report were able to capture increased revenue because more people are covered – although all states with these taxes will get in on this action. For example, Arkansas brought in $4.7 million in 2014 and will bring in almost $30 million in 2015 as a result of having closed the coverage gap.

The results are clear – drawing down federal funds to cover more people is good for state budgets. It’s also exciting that both Arkansas and Kentucky were able to calculate that their savings and revenue will more than pay for expansion through 2021. We only hope that policymakers in states with a remaining coverage gap hear this good news loud and clear!