Thirty group health plans have been put on notice by the federal government for not covering behavioral health services and potentially violating mental health parity laws.
A report released Tuesday by the Labor Department doesn't name specific companies but gave examples of violations, including a "large service provider" administering claims for hundreds of self-funded plans excluding therapy to treat autism. Some plans failed to cover medication-assisted treatment, viewed by addiction specialists as the "gold-standard" for treating opioid use disorder.
In all, the Labor Department and the Centers for Medicare and Medicaid Services issued "initial determination" letters to 30 plans, finding 48 limitations or exclusions on coverage for mental health services that were more stringent than comparable medical or surgical services, a violation of the mental health parity law passed by Congress in 2008.
The department will not release the names of insurers found in violations of the law until determinations are made final. Those violations will be made public in the agency's report to Congress next year.
"The report's findings clearly indicate that health plans and insurance companies are falling short of providing parity in mental health and substance-use disorder benefits, at a time when those benefits are needed like never before," said Labor Secretary Marty Walsh.
Advocates and experts have long suspected that plans were not fully complying with parity laws, but the government had limited authority to enforce parity until last year.
A provision included in the 2020 government funding bill requires group health plans conduct analyses on their so-called non-quantitative treatment limitations to ensure their exclusions or limitations on treatment are in compliance with parity laws. Those reports must be provided to the government upon request.
The Labor Department requested reports from 156 plans and issuers between Feb. 10 and Oct. 31 of last year. Of the reports reviewed so far, 80 were deemed "insufficient" to determine parity.
The Association for Behavioral Health and Wellness, a national group for payers that manages behavioral health insurance benefits, said it "fully supports the concept of mental health parity" but blamed the Labor Department for not issuing enough guidance and clarity around compliance with the new rules.
"Clear, detailed guidance for NQTL analysis is needed to ensure greater compliance with this landmark law," the group said in a press release Tuesday.
David Lloyd, senior policy adviser for The Kennedy Forum, which advocates for better access to behavioral healthcare, argues that insurers have been making excuses to avoid fully complying with parity laws for several years now and analyses on treatment limitations were recommended before they were required by Congress in 2020. The fundamental requirements on treatment limitations have not changed since 2014, he noted.
"Sometimes the plans will say to us or you will hear them say 'we're still figuring out how to comply.' It's clearly no longer an excuse, if it ever was," he said.
"They should know the requirements of the law, particularly for some of the areas where violations were found." He said plans should begin putting together their reports if they have not already done so.
Final determinations for violations have not yet been made, and other reports are still being reviewed, but the Labor Department said early reviews show some insurers not complying with parity laws.
One of the most common violations was limitations or exclusions or coverage of therapy for autism.
Nine insurers were found not to cover the therapy—called applied behavior analysis—a primary treatment for autism delivered by a behavioral specialist multiple times a week over the course of months or years.
Four insurers were found to have limited or excluded medication-assisted treatment for opioid use disorder and had unlawful pre-authorization or pre-certification requirements for behavioral health services.
In an example provided by the Labor Department, a large, self-funded health plan covering more than 7,600 participants specifically excluded methadone and naltrexone as treatment for substance use disorders but did not have similar restrictions on medications that treat medical or surgical conditions.
Four insurers also limited or excluded nutritional counseling for eating disorders , including two large plans that offered coverage of those services for people with diabetes.
After being contacted by the Labor Department, the two large plans the plans agreed to remove the exclusion, affecting more than 1.2 million members of those plans, according to the department.
As of Oct. 31, 26 plans and issuers have made plans to make changes to more than 40 limitations on behavioral health treatment after being contacted by the department.
If plans don't come into compliance with parity laws, then they must notify their enrollees and the Labor Department will share the findings with the state the group health plan is located in.
But the department is also asking Congress to give it the authority to impose civil monetary penalties for violations "to greatly strengthen the protections of the law."
"In the absence of the authority to impose civil monetary penalties, (the Labor Department) is limited in its ability to ensure appropriate corrective action in response to findings of non-compliance," the report states.
Congressional leaders are aiming to pass a legislative package this year expanding access to mental healthcare, and improving compliance with parity laws is expected to be part of the discussion.
"If given the right tools, I am confident that true mental health parity can become a reality in the American healthcare system," Senate Finance Committee Chairman Ron Wyden (D-Ore.) said in a press release Wednesday commenting on the Labor Department's report.
Wyden's committee is working on a bipartisan mental health package and the Senate health committee and House Ways and Means committee will also have hearings on the issue in February.