Equal Coverage for Treatment is Law, But Enforcement Lags

John SniffenAdvocacy, La Hacienda

Image from the Parity at 10 Campaign

Image from the Parity at 10 Campaign.

Insurance coverage for treatment of substance use disorders and mental health issues is supposed to be equal to what is provided for medical and surgical services. That was the purpose of the 2008 Mental Health Parity and Addiction Equity Act passed by Congress 10 years ago this fall.

In theory it sounds simple.

“For example, if a patient’s insurance policy does not limit the number of times they can be treated for heart disease, it should not limit the number of times they can be treated for substance use disorders,” says Outpatient Services Administrator Sherri Layton.

The truth, however, is that many insurance policies have not caught up with the law, and enforcement of it—relegated to the states—has lagged. Passage of the Affordable Care Act in 2010 also clogged the agendas of state insurance commissions.

There have been advances during the past 10 years, but there are still many problems.

“In one recent month, we had four cases of people attempting to access treatment here who had already used up the lifetime maximums for substance use disorders as stipulated in their policies.”

Challenging the Policies

Those policies violate the law, but it is up to policy holders to contest the limitations, says Sherri, but it’s not a quick or easy process.

They can ask the insurance provider to correct the policies. If the company refuses, there are a couple of other options.

Persons needing treatment can talk with the Office of Behavioral Health Ombudsman in the Texas Department of Health and Human Services. That office, created by the state legislature in 2017, helps people find ways to solve problems with insurance coverage and to better understand their rights.

Or they can file a complaint with the Texas Department of Insurance. But someone needing treatment is not usually in a good position to do that.

“It’s on the individual or a family member to file a complaint. The challenge is that people seeking treatment are often at a crisis point in their life and don’t have the stamina,” says Sherri.

“The process is not easy. I tried to work through it. I’m knowledgeable about this, and it’s overwhelming to me.”

Government Improvements

Texas did little to enforce the parity law for eight years, but that is changing, says Sherri.

In addition to creation of the Office of Behavioral Health Ombudsman, the Texas Legislature created the Parity Work Group, on which Sherri serves, to develop a three-year plan for bringing about enforcement of and compliance with the parity law.

The Texas House Select Committee on Mental Health’s annual report notes, however, that “Parity is a very complex issue with numerous caveats depending on the type of health care plan held, the coverage offered in the health plan, and the insurance provider.”

More legislative action has also come from Washington. This fall Congress passed major bipartisan legislation in response to the opioid crisis. One of its provisions is that the federal government will examine how the states are enforcing the 2008 parity law.