Mental Health and Substance Use
Employers' Insurance Coverage Maintained or Enhanced Since Parity Act, but Effect of Coverage on Enrollees Varied Gao ID: GAO-12-63 November 30, 2011The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that employers who offer health insurance coverage for mental health conditions and substance use disorders (MH/SU) provide coverage that is no more restrictive than that offered for medical and surgical conditions. Employers were required to comply with the law for coverage that began on or after October 3, 2009. The Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Department of the Treasury share oversight for MHPAEA. MHPAEA also requires GAO to examine trends in health insurance coverage of MH/SU. This report describes (1) the extent to which employers cover MH/SU through private health insurance plans, and how this coverage has changed since 2008; and (2) what is known about the effect of health insurance coverage for MH/SU on enrollees' health care expenditures; access to, or use of, MH/SU services; and health status. GAO surveyed a random sample of employers about their MH/SU coverage for the most current plan year and for 2008. GAO received usable responses from 168 employers--a 24 percent response rate. The survey results are not generalizable; rather, they provide information limited to responding employers' MH/SU coverage. GAO reviewed published national employer surveys on health insurance coverage and interviewed officials from DOL, HHS, and other experts. GAO also reviewed studies that evaluated the effect of MH/SU coverage on enrollees' expenditures, access to, or use of, MH/SU services, and health status.
Most employers continued to offer coverage of MH/SU since MHPAEA was passed. Of the employers that responded to GAO's survey, 96 percent offered coverage of MH/SU for the current plan year and for 2008, before MHPAEA was passed. Approximately 2 percent of employers reported offering coverage for only mental health conditions but not substance use disorders for the current plan year and for 2008. Conversely, about 2 percent of employers reported discontinuing their coverage of both MH/SU or only substance use disorders in the current plan year. The types of MH/SU diagnoses included and excluded in employers' MH/SU benefits remained consistent between the current plan year and 2008. Of the employers who provided information about diagnoses included in their MH/SU benefits for both the current plan year and 2008, 34 percent reported that their most popular plan in the current plan year excluded at least one MH/SU diagnosis from their benefits, and 39 percent of employers reported excluding at least one MH/SU diagnosis from their benefits for the 2008 plan year. The most common change to MH/SU benefits reported among those who responded to the survey was enhancing benefits through the removal of treatment limitations, such as the number of allowed office visits. Reported use of lifetime dollar limits on MH/SU treatments also declined from 2008 to the current plan year. Among employers who reported information on cost-sharing, copayments and coinsurance amounts for in-network providers generally stayed about the same, fluctuating minimally from 2008 to the current plan year. Published national employer surveys on health insurance coverage also reported results consistent with GAO's survey data. Employers may continue to modify certain nonfinancial requirements--such as changes to the services they cover (the scope of services) and nonquantitative treatment limits--in their MH/SU benefits in response to agencies' issuance of final implementing regulations for MHPAEA. Officials from DOL and HHS reported that the final regulations may provide additional detail on these nonfinancial requirements. Research suggests that coverage for MH/SU has a varied effect on enrollees. Research examining the effect of health insurance coverage for MH/SU on enrollee expenditures generally found that the implementation of parity requirements reduced enrollee expenditures. Studies that examined the effect of health insurance coverage for MH/SU on enrollee access to, and use of, MH/SU services had mixed results, with some studies indicating there was little to no effect and others indicating that there was some effect--such as finding that restricting coverage had a negative effect on use of services. Little research has explored the relationship between health insurance coverage and health status. Of the studies we reviewed, two examined the effect of health insurance coverage for MH/SU on enrollee health status and found different effects. GAO provided a draft of the report to DOL and HHS. Both agencies provided technical comments, which have been incorporated as appropriate.
GAO-12-63, Mental Health and Substance Use: Employers' Insurance Coverage Maintained or Enhanced Since Parity Act, but Effect of Coverage on Enrollees Varied
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
November 2011:
Mental Health and Substance Use:
Employers' Insurance Coverage Maintained or Enhanced Since Parity Act,
but Effect of Coverage on Enrollees Varied:
GAO-12-63:
GAO Highlights:
Highlights of GAO-12-63, a report to congressional committees.
Why GAO Did This Study:
The Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (MHPAEA) requires that employers who
offer health insurance coverage for mental health conditions and
substance use disorders (MH/SU) provide coverage that is no more
restrictive than that offered for medical and surgical conditions.
Employers were required to comply with the law for coverage that began
on or after October 3, 2009. The Department of Labor (DOL), the
Department of Health and Human Services (HHS), and the Department of
the Treasury share oversight for MHPAEA. MHPAEA also requires GAO to
examine trends in health insurance coverage of MH/SU.
This report describes (1) the extent to which employers cover MH/SU
through private health insurance plans, and how this coverage has
changed since 2008; and (2) what is known about the effect of health
insurance coverage for MH/SU on enrollees‘ health care expenditures;
access to, or use of, MH/SU services; and health status. GAO surveyed
a random sample of employers about their MH/SU coverage for the most
current plan year and for 2008. GAO received usable responses from 168
employers”-a 24 percent response rate. The survey results are not
generalizable; rather, they provide information limited to responding
employers‘ MH/SU coverage. GAO reviewed published national employer
surveys on health insurance coverage and interviewed officials from
DOL, HHS, and other experts. GAO also reviewed studies that evaluated
the effect of MH/SU coverage on enrollees‘ expenditures, access to, or
use of, MH/SU services, and health status.
What GAO Found:
Most employers continued to offer coverage of MH/SU since MHPAEA was
passed. Of the employers that responded to GAO‘s survey, 96 percent
offered coverage of MH/SU for the current plan year and for 2008,
before MHPAEA was passed. Approximately 2 percent of employers
reported offering coverage for only mental health conditions but not
substance use disorders for the current plan year and for 2008.
Conversely, about 2 percent of employers reported discontinuing their
coverage of both MH/SU or only substance use disorders in the current
plan year. The types of MH/SU diagnoses included and excluded in
employers‘ MH/SU benefits remained consistent between the current plan
year and 2008. Of the employers who provided information about
diagnoses included in their MH/SU benefits for both the current plan
year and 2008, 34 percent reported that their most popular plan in the
current plan year excluded at least one MH/SU diagnosis from their
benefits, and 39 percent of employers reported excluding at least one
MH/SU diagnosis from their benefits for the 2008 plan year. The most
common change to MH/SU benefits reported among those who responded to
the survey was enhancing benefits through the removal of treatment
limitations, such as the number of allowed office visits. Reported use
of lifetime dollar limits on MH/SU treatments also declined from 2008
to the current plan year. Among employers who reported information on
cost-sharing, copayments and coinsurance amounts for in-network
providers generally stayed about the same, fluctuating minimally from
2008 to the current plan year. Published national employer surveys on
health insurance coverage also reported results consistent with GAO‘s
survey data. Employers may continue to modify certain nonfinancial
requirements-”such as changes to the services they cover (the scope of
services) and nonquantitative treatment limits”in their MH/SU benefits
in response to agencies‘ issuance of final implementing regulations
for MHPAEA. Officials from DOL and HHS reported that the final
regulations may provide additional detail on these nonfinancial
requirements.
Research suggests that coverage for MH/SU has a varied effect on
enrollees. Research examining the effect of health insurance coverage
for MH/SU on enrollee expenditures generally found that the
implementation of parity requirements reduced enrollee expenditures.
Studies that examined the effect of health insurance coverage for
MH/SU on enrollee access to, and use of, MH/SU services had mixed
results, with some studies indicating there was little to no effect
and others indicating that there was some effect”such as finding that
restricting coverage had a negative effect on use of services. Little
research has explored the relationship between health insurance
coverage and health status. Of the studies we reviewed, two examined
the effect of health insurance coverage for MH/SU on enrollee health
status and found different effects.
GAO provided a draft of the report to DOL and HHS. Both agencies
provided technical comments, which have been incorporated as
appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-12-63] or key
components. For more information, contact John E. Dicken at (202) 512-
7114 or dickenj@gao.gov.
[End of section]
Contents:
Letter:
Background:
Employers Continued to Offer Coverage or Enhanced Benefits for Mental
Health Conditions and Substance Use Disorders Since the Enactment of
MHPAEA:
Research Suggests That Coverage for Mental Health Conditions and
Substance Use Disorders Has a Varied Effect on Enrollees:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Articles Reviewed on the Effect of Health Insurance
Coverage on Enrollees:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Average Cost-Sharing for In-Network Office Visits and
Outpatient Services in the 2008 Plan Year and in the Current Plan Year:
Table 2: Studies Published between January 2000 and March 11, 2011,
Addressing the Effect of Health Insurance Coverage for Mental Health
Conditions and Substance Use Disorders on Enrollees' Health Care
Expenditures:
Table 3: Studies Published between January 2000 and March 11, 2011,
Addressing the Effect of Health Insurance Coverage for Mental Health
Conditions and Substance Use Disorders on Enrollees' Access to, or Use
of, MH/SU Services:
Table 4: Studies Published between January 2000 and March 11, 2011,
Addressing the Effect of Health Insurance Coverage for Mental Health
Conditions and Substance Use Disorders on Enrollees' Health Status:
Figures:
Figure 1: Percentage of Employers Including Broad MH/SU Diagnoses in
Their Most Popular Plan, 2008 Plan Year and Current Plan Year:
Figure 2: Percentage of Employers Including Treatment Limitations for
MH/SU in Their Most Popular Plan, 2008 Plan Year and Current Plan Year:
Abbreviations:
ASPE: The Assistant Secretary for Planning and Evaluation:
DOL: Department of Labor:
FEHBP: Federal Employees Health Benefits Program:
HHS: Department of Health and Human Services:
IFR: Interim Final Rules Under the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008:
Kaiser/HRET: Kaiser Family Foundation and Health Research and
Educational Trust:
MBHO: managed behavioral health organization:
MHPAEA: Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008:
MH/SU: mental health conditions and substance use disorders:
NQTL: nonquantitative treatment limitation:
SPD: summary plan document:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
November 30, 2011:
Congressional Committees:
An estimated 26 percent of American adults suffer from some type of
mental health condition each year, with about 6 percent of them
suffering from a severe mental health condition such as schizophrenia
or major depression.[Footnote 1] An estimated 9 percent of Americans
12 or older were classified with a substance use disorder in 2010.
[Footnote 2] In 2008, 13 percent of American adults received mental
health treatment services. For those adults with a severe mental
health condition, just over half--59 percent--received mental health
treatment services.[Footnote 3] When mental health conditions are left
untreated, they are more likely to result in hospitalizations. In
2006, one in five hospitalizations in the United States included a
mental health condition either as a primary or secondary diagnosis.
[Footnote 4] Similarly, when substance use disorders are inadequately
treated, they can complicate care for costly medical conditions, such
as diabetes.
[End of section]
Historically, employer-sponsored health care coverage offered through
private health insurance plans has typically provided lower levels of
coverage for the treatment of mental health conditions and substance
use disorders (MH/SU) than for the treatment of medical and surgical
conditions (medical/surgical). Consequently, patients with MH/SU may
not have received timely or sufficient treatment, or may have incurred
high out-of-pocket costs. From 2007 to 2010, about 38 percent of
Americans 12 or older who needed treatment for substance use disorders
did not receive treatment because of a lack of coverage, and could not
afford the cost without coverage.[Footnote 5]
To help address the discrepancies in health care coverage between
MH/SU and medical/surgical, Congress passed the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
(MHPAEA).[Footnote 6] The Department of Labor (DOL), the Department of
Health and Human Services (HHS), and the Department of the Treasury
(Treasury) share joint oversight responsibilities for MHPAEA and for
issuing implementing regulations. Under MHPAEA, group health plan
sponsors, including employers, must ensure that coverage of MH/SU be
no more restrictive than coverage for medical/surgical.[Footnote 7]
Specifically, employers that choose to cover MH/SU must provide
coverage equivalent to that offered for medical/surgical with respect
to annual and lifetime dollar limits, financial requirements such as
copayments, treatment limitations such as the number of covered
outpatient office visits or hospital days, and the availability of in-
and out-of-network providers. For employers that choose to cover
MH/SU, MHPAEA does not require coverage of specific diagnoses.
MHPAEA also requires us to examine trends in coverage for MH/SU. For
this study, we report on: (1) the extent to which employers cover
MH/SU through private health insurance plans, and how this coverage
has changed since MHPAEA was passed in 2008; and (2) what is known
about the effect of health insurance coverage for MH/SU on enrollees'
health care expenditures; access to, or use of, MH/SU services; and
health status.
To determine the extent to which employers cover MH/SU both currently
and in 2008, we surveyed a stratified random sample of small, medium,
large, and very large employers about their most popular health plans
for the most current plan year--either 2011 or 2010--as well as for
2008. We conducted a survey of employers because we were unable to
identify a published national employer survey that included specific
detailed information about employers' MH/SU benefits prior to and
following MHPAEA--namely, information about diagnoses included in or
excluded from coverage. We fielded our web-based survey between May
18, 2011, and July 1, 2011, to 707 employers, selected from the
sampling frame we developed using the Lexis Nexis corporate database.
[Footnote 8] We received usable responses from 168 employers, after
following up with nonrespondents to encourage their participation, for
a 24 percent response rate. All 168 employers offered coverage of
mental health conditions, substance use disorders, or both, in either
the current plan year, 2008 plan year, or both plan years. Of the 168
employers that provided usable survey responses, a subset of employers
answered at least one detailed benefits question for only one plan
year--the current plan year or the 2008 plan year. As a result, the
denominator for our calculations varied depending on the question we
analyzed. Given our overall response rate of 24 percent, our survey
results are not generalizable. Rather, the survey responses provide
information limited to responding employers' coverage of MH/SU in the
current plan year and 2008 plan year. We did not verify the accuracy
of the employers' responses or assess compliance with MHPAEA.
To supplement the data collected from our survey, we reviewed the
results of published national employer surveys from the Kaiser Family
Foundation and Health Research and Educational Trust (Kaiser/HRET) and
Mercer. These surveys provided generalizable information on employers'
coverage of MH/SU. We also conducted interviews with agency officials
from DOL and HHS who had expertise in MH/SU issues, as well as with
other experts, to learn about the implementation of MHPAEA and trends
in employers' coverage of MH/SU. We did not interview Treasury
officials because the focus of this engagement did not relate to that
agency's scope of responsibility. Lastly, we conducted detailed
interviews with a nongeneralizable sample of four employer survey
respondents to obtain more detailed information about the employers'
coverage of MH/SU, and their reasons for making or not making changes
to coverage after MHPAEA took effect.[Footnote 9]
To describe what is known about the effect of health insurance
coverage for MH/SU on enrollees' health care expenditures, access to,
or use of, MH/SU services, and health status, we conducted a
literature review of peer-reviewed journals and other periodicals
published between January 1, 2000, and March 11, 2011. We also
included articles in our literature review that were suggested to us
by the experts we interviewed, as well as studies that were referenced
in the articles found during our initial search. In total, we reviewed
34 studies as part of our literature review.
Appendix I provides more details about our scope and methodology.
Appendix II provides a list of articles we reviewed as part of our
literature review.
We conducted our work from December 2010 to September 2011 in
accordance with all sections of GAO's Quality Assurance Framework that
are relevant to our objectives. The framework requires that we plan
and perform the engagement to obtain sufficient and appropriate
evidence to meet our stated objectives and to discuss any limitations
in our work. We believe that the information and data obtained, and
the analysis conducted, provide a reasonable basis for any findings in
this product.
Background:
Most Americans obtain their health insurance coverage through the
workplace. Employers typically offer health insurance coverage for
employees on an annual basis through one or more health plans. Each
plan year, employers can decide how many health plans to offer,
whether to include coverage for MH/SU in the health plans offered, and
what type of benefits[Footnote 10] those plans can include as part of
their coverage.[Footnote 11],[Footnote 12] Additionally, employers may
determine if their plans' MH/SU benefits will be managed by the same
health insurer that manages their medical/surgical benefits, or if
they will be managed by a separate organization that specializes in
MH/SU benefits--known as a managed behavioral health organization
(MBHO).
Health insurance benefits commonly include cost-sharing provisions
requiring enrollees to pay for a portion of their health care. These
provisions can be applied to both MH/SU and medical/surgical benefits,
and include:
* Deductibles: Required payments of a specified amount made by
enrollees for services before the health insurer begins to pay.
* Copayments: Payments made by enrollees of a specified flat dollar
amount, usually on a per-unit-of-service basis, with the health
insurer reimbursing some portion of the remaining charges. The payment
is made after the deductible is met and until the out-of-pocket
expense maximum is reached--that is, the maximum amount that enrollees
have to pay per year for all covered medical expenses.
* Coinsurance: A percentage payment made by enrollees after the
deductible is met and until the out-of-pocket expense maximum is
reached.
Prior to the implementation of MHPAEA, private health insurance plans
offered through employers that covered MH/SU typically provided lower
levels of coverage for the treatment of these illnesses than for the
treatment of physical illnesses.[Footnote 13] Employers often limited
the coverage of MH/SU through the use of plan design features that
were more restrictive for MH/SU benefits than for medical/surgical
benefits. Prior to MHPAEA, MH/SU benefits were commonly subject to
higher cost-sharing features such as deductibles, copayments, or
coinsurance; more restrictive treatment limitations such as the number
of covered hospital days or outpatient office visits; and limited out-
of-network providers.[Footnote 14] Also, there were concerns that
employers would limit the MH/SU treatment enrollees could receive by
excluding specific MH/SU diagnoses, such as eating disorders, from
their benefits.
For example, prior to MHPAEA, an employer's plan could cover unlimited
hospital days and outpatient office visits and require 20 percent
coinsurance for outpatient office visits for medical/surgical
treatment while, for MH/SU, that same plan could cover only 30
hospital days and 20 outpatient office visits per year and impose 50
percent coinsurance for outpatient office visits. Additionally, an
employer's plan might limit the MH/SU diagnoses for which treatment
was covered.
Employers provided more limited coverage of MH/SU prior to MHPAEA
primarily because of concerns about the cost of providing coverage for
individuals with MH/SU.[Footnote 15] Concerns about the high costs
associated with long-term, intensive psychotherapy and extended
hospital stays, particularly for some diagnoses such as schizophrenia
or major depression, could have prompted employers to impose treatment
limitations on outpatient office visits and hospital days, and limits
on annual or lifetime dollar amounts for treatment of MH/SU.
To help address the discrepancies in health care coverage between
mental illnesses and physical illnesses, Congress passed MHPAEA which
strengthened federal parity requirements.[Footnote 16] MHPAEA requires
that coverage terms for MH/SU--when those services are offered--be no
more restrictive than coverage terms for medical/surgical services.
Under MHPAEA, employers are not required to offer MH/SU coverage.
However, those plans that do offer mental health or substance use
disorder coverage were required to comply with MHPAEA's parity
requirements for their health plan year that began on or after October
3, 2009.[Footnote 17]
On February 2, 2010, DOL, HHS, and Treasury issued the Interim Final
Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 (IFR), which contain provisions
regarding coverage of MH/SU as a result of MHPAEA.[Footnote 18] The
provisions in the IFR, which employers had to implement for the plan
year beginning on or after July 1, 2010, address various aspects of
implementing parity for coverage of MH/SU, including classifications
of benefits and nonquantitative treatment limitations (NQTL).
The IFR specifies six classifications of benefits within which parity
must be applied: (1) inpatient, in-network; (2) inpatient, out-of-
network; (3) outpatient, in-network; (4) outpatient, out-of-network;
(5) emergency care; and (6) prescription drugs. The IFR further
specifies that plans choosing to cover MH/SU benefits must offer the
MH/SU benefits within any one classification when medical/surgical
benefits are offered at that same classification. Thus, for plans that
cover MH/SU benefits, if medical/surgical services are covered for in-
patient, out-of-network care, the plan must also cover MH/SU services
for in-patient, out-of-network care.
An NQTL is a treatment limitation that is not expressed numerically
but still limits the scope or duration of benefits for treatment under
a health plan.[Footnote 19] Examples of NQTLs, some of which are noted
in the IFR include: standards for provider admission to participate in
a network; plan methods for determining usual, customary, and
reasonable charges; pre-authorization of services; and utilization
review.[Footnote 20] The IFR stipulates that employers must ensure
that NQTLs are comparable across benefit classifications. Generally,
if an NQTL is used for MH/SU services within a classification, it is
to be applied no more stringently than an NQTL for medical/surgical
services within that same classification.[Footnote 21]
Employers Continued to Offer Coverage or Enhanced Benefits for Mental
Health Conditions and Substance Use Disorders Since the Enactment of
MHPAEA:
Most employers that responded to our survey continued to offer
coverage of MH/SU through private insurance plans following the
implementation of MHPAEA. The types of diagnoses and treatments
included in employers' MH/SU benefits remained largely unchanged, and
some employers enhanced their MH/SU benefits by removing coverage
limits as a result of MHPAEA requirements. After the issuance of the
final regulations implementing MHPAEA, employers may make additional
changes to their MH/SU benefits.
Most Employers Continued to Offer Coverage for Mental Health
Conditions and Substance Use Disorders:
Most employers that responded to our survey offered coverage of MH/SU
both in their most current plan year--2011 or 2010--and in 2008,
before MHPAEA was passed. Of the employers that responded to our
survey about their coverage of MH/SU for both plan years, about 96
percent offered coverage for MH/SU for the current plan year and for
2008.[Footnote 22],[Footnote 23] Approximately 2 percent of employers
reported that they offered coverage for only mental health conditions
in 2008 but not substance use disorders, and continued to offer
coverage for only mental health conditions in the current plan year.
Conversely, a small percentage of employers--about 2 percent of those
employers that responded to our survey about their coverage of MH/SU
for both plan years--reported discontinuing their coverage of both MH/
SU or only substance use disorders in the current plan year. One
employer that discontinued offering coverage of mental health reported
that it did so to control health insurance costs. Another employer
reported that it ceased to offer coverage of substance use disorders
because it did not want to cover these disorders without treatment
limitations. Under MHPAEA, if substance use disorders are covered, any
treatment limitations for the substance use benefits must be used on
par with those used in medical/surgical benefits.
Published employer surveys also reported that few employers
discontinued coverage of MH/SU since MHPAEA was passed. According to
Kaiser/HRET's Employer Health Benefits 2010 Annual Survey, less than 2
percent of employers reported eliminating coverage for MH/SU as a
result of MHPAEA.[Footnote 24] Mercer reported in its National Survey
of Employer-Sponsored Health Plans that the percentage of employers
surveyed that reported offering coverage for MH/SU was consistent from
2008 to 2010. Specifically, about 90 percent of employers surveyed in
2008 and 92 percent of employers surveyed in 2010 reported offering
coverage for MH/SU.[Footnote 25] According to both Mercer's 2008
survey and 2010 survey, offering coverage of MH/SU was most common
among employers with 500 or more employees, at about 97 percent.
Additionally, about 90 percent of employers with fewer than 500
employees surveyed in 2008 and 92 percent of employers with fewer than
500 employees surveyed in 2010 indicated that they offered coverage
for MH/SU.
Agency officials also told us that based on their review of trend data
and information on employer's coverage of MH/SU, employers appeared to
continue to offer coverage of MH/SU since MHPAEA was passed. In
addition, representatives from large insurance companies, a health
benefits consulting firm, and an MBHO told us that most employers with
whom they interact continued to offer coverage of MH/SU since MHPAEA
was passed. According to other health benefits experts, most employers
they knew of generally experienced minimal challenges in complying
with the MHPAEA requirements. Representatives from medium, large, and
very large employers with whom we spoke told us that the process for
making changes to their health plans to comply with MHPAEA was
relatively easy for them because they relied on their insurance
brokers or health benefits consultants to inform them of the
requirements and assist them in making necessary changes.
Diagnoses and Treatments Included in Benefits Remained Largely
Unchanged and Some Employers Enhanced Benefits by Removing Coverage
Limits:
Employers have not substantially changed the diagnoses and treatments
that are included in their MH/SU benefits. However, fewer employers
reported excluding at least one broad MH/SU diagnosis and more
employers reported excluding a treatment related to MH/SU in the
current plan year than for 2008. Some employers enhanced their MH/SU
benefits by removing coverage limits and modifying cost-sharing for
MH/SU in response to MHPAEA requirements.
Diagnoses and Treatments:
The types of MH/SU diagnoses included and excluded from employers' MH/
SU benefits remained consistent between the current plan year and
2008.[Footnote 26] About 91 percent of employers that responded to the
question in our survey about the diagnoses included in their MH/SU
benefits for both the current plan year and 2008 plan year[Footnote
27] reported their MH/SU benefits included the same broad diagnoses in
their most popular health plan in the current plan year and in 2008.
The other 9 percent of employers reported including more broad
diagnoses in their MH/SU benefits for the current plan year than in
the 2008 plan year. Most employers that provided information about
diagnoses included in MH/SU benefits for both years reported that they
included all types of broad mental health diagnoses in their MH/SU
benefits for both plan years. Five of these broad diagnoses were
covered by over 90 percent of employers for both the current plan year
and 2008--mental disorders due to a general medical condition,
substance-related disorders, schizophrenia and other psychotic
disorders, mood disorders, and anxiety disorders (see fig. 1).
Figure 1: Percentage of Employers Including Broad MH/SU Diagnoses in
Their Most Popular Plan, 2008 Plan Year and Current Plan Year:
[Refer to PDF for image: table]
Diagnosis: Disorders usually diagnosed in infancy, childhood, or
adolescence;
2008 plan year: 87%[A];
Current plan year: 88%[A].
Diagnosis: Delirium, dementia, and amnestic and other cognitive
disorders;
2008 plan year: 88%[A];
Current plan year: 93%.
Diagnosis: Mental disorders due to a general medical condition;
2008 plan year: 93%[B];
Current plan year: 96%[B].
Diagnosis: Substance-related disorders;
2008 plan year: 97%[B];
Current plan year: 97%[B].
Diagnosis: Schizophrenia and other psychotic disorders;
2008 plan year: 94%[B];
Current plan year: 94%[B].
Diagnosis: Mood disorders;
2008 plan year: 93%[B];
Current plan year: 91%[B].
Diagnosis: Anxiety disorders;
2008 plan year: 97%[B];
Current plan year: 97%[B].
Diagnosis: Somatoform disorders;
2008 plan year: 81%[A];
Current plan year: 82%[A].
Diagnosis: Factitious disorders;
2008 plan year: 81%[A];
Current plan year: 81%[A].
Diagnosis: Dissociative disorders;
2008 plan year: 85%[A];
Current plan year: 85%[A].
Diagnosis: Sexual and gender identify disorders;
2008 plan year: 70%[A];
Current plan year: 70%[A].
Diagnosis: Eating disorders;
2008 plan year: 88%[A];
Current plan year: 88%[A].
Diagnosis: Sleep disorders;
2008 plan year: 87%[A];
Current plan year: 88%[A].
Diagnosis: Impulse-control disorders;
2008 plan year: 82%[A];
Current plan year: 84%[A].
Diagnosis: Adjustment disorders;
2008 plan year: 81%[A];
Current plan year: 81%[A].
Diagnosis: Personality disorders;
2008 plan year: 84%[A];
Current plan year: 85%[A].
[A] Less than 90 percent of employers included this diagnosis.
[B] Ninety percent or more of employers included this diagnosis in
their most popular plan in their most popular plan.
Source: GAO employer survey of mental health and substance use
coverage.
Note: Of the 168 employers that provided usable responses to our
survey, 67 employers responded to the survey question about which
diagnoses were included in the MH/SU benefits for both the employer's
2008 plan year and current plan year--either 2011 or 2010.
[End of figure]
Of the employers that responded to our survey question about the
diagnoses included in their MH/SU benefits for both the current plan
year and 2008 plan year,[Footnote 28] 34 percent reported that their
most popular plan in their current plan year excluded at least one
broad MH/SU diagnosis from their benefits, and 39 percent reported
this for the 2008 plan year.[Footnote 29] Approximately 9 percent of
employers that answered detailed benefits questions in our survey
reported that their most popular plan for the current plan year
excluded at least one specific mental health diagnosis subcategory
within a broader mental health diagnosis and 2 percent excluded at
least one specific substance use disorder subcategory. Similarly,
approximately 10 percent reported excluding at least one specific
mental health diagnosis subcategory and 2 percent excluded at least
one specific substance use disorder subcategory for the 2008 plan
year.[Footnote 30] Examples of specific diagnosis subcategories
excluded by our survey respondents included developmental disorders,
learning disorders, mental retardation, sexual deviation and
dysfunction, and relational disorders, such as marriage or family
problems.
Similarly, according to Mercer's 2010 National Survey of Employer-
Sponsored Health Plans, 1 percent of employers with 500 or more
employees and less than 1 percent of employers with fewer than 500
employees reported excluding additional diagnoses from their MH/SU
benefits as a result of MHPAEA. Representatives from a large health
insurer, a health benefits consulting firm, an insurance broker
organization, and an advocacy group also reported that employers with
whom they interact generally included the same number and type of
diagnoses in their MH/SU benefits for the current plan year as they
did prior to MHPAEA's implementation.
In addition to exclusions of diagnoses, some employers also choose to
exclude specific treatments from their MH/SU benefits. Of the
employers that responded to the question in our survey about excluding
a specific treatment for MH/SU, approximately 41 percent reported
excluding a specific treatment for MH/SU from their most popular
health plan in the current plan year, while 33 percent reported doing
so for their most popular health plan in the 2008 plan year.[Footnote
31]
According to representatives from an advocacy organization and an
institution that conducts employer-based surveys on health insurance
coverage, some employers choose to exclude specific treatments related
to certain MH/SU diagnoses from their MH/SU benefits than to exclude
the diagnosis itself. For example, representatives from an MBHO, a
health benefits consulting firm, and an institution that conducts
employer-based surveys on health insurance coverage told us that
employers may exclude the treatment of "applied behavioral analysis"
for autism, citing concerns about the treatment's effectiveness,
rather than excluding coverage for autism.
Coverage Limits:
The most common change to MH/SU benefits reported among those that
responded to our survey was enhancing benefits through the removal of
treatment limitations, such as the number of allowed office visits or
inpatient days. About 7 percent of employers that answered detailed
benefits questions in our survey reported limits on the number of
allowed office visits for mental health conditions in the current plan
year, compared to 35 percent in 2008; and 9 percent reported limits on
the number of allowed inpatient days for treatment of mental health
conditions, compared to 29 percent in 2008. Similarly, 8 percent of
employers that answered detailed benefits questions in our survey
reported limits on the number of allowed office visits for substance
use disorders, compared to 33 percent in 2008; and 8 percent reported
limits on the number of allowed inpatient days for treatment of
substance use disorders, compared to 27 percent in 2008 (see fig. 2).
Figure 2: Percentage of Employers Including Treatment Limitations for
MH/SU in Their Most Popular Plan, 2008 Plan Year and Current Plan Year:
[Refer to PDF for image: 2 vertical bar graphs]
Treatment limitations for mental health conditions:
2008 plan year:
Allowed number of office visits: 35;
Allowed number of inpatient days: 7;
Current plan year:
Allowed number of office visits: 29;
Allowed number of inpatient days: 9.
Treatment limitations for substance abuse disorders:
2008 plan year:
Allowed number of office visits: 33;
Allowed number of inpatient days: 8;
Current plan year:
Allowed number of office visits: 27;
Allowed number of inpatient days: 8.
Source: GAO employer survey of mental health and substance abuse
coverage.
Note: The calculations for the 2008 plan year are based on 123
employer responses and the calculations for the employer's current
plan year--either 2011 or 2010--are based on 130 employer responses.
[End of figure]
Reported use of lifetime dollar limits on MH/SU treatments also
declined from 2008 to the current plan year.[Footnote 32] About 5
percent of employers that answered detailed benefits questions in our
survey reported lifetime dollar limits on treatments for MH/SU for the
current plan year, compared to 20 percent in 2008.[Footnote 33]
Employers that reported lifetime dollar limits on mental health
treatments for the current plan year generally told us that these
limits applied to all treatments for MH/SU or that they applied to all
treatments covered by the plan--including both MH/SU and medical/
surgical.
Kaiser/HRET's Employer Health Benefits 2010 Annual Survey reported
that of the 31 percent of employers surveyed that made changes in
their mental health benefits as a result of MHPAEA, two-thirds of
these employers reported eliminating coverage limits on mental health
treatments, the most common change made by employers. Mercer's 2010
National Survey of Employer-Sponsored Health Plans also found that the
elimination of treatment limitations and annual or lifetime dollar
limits were common changes made by employers, reporting that 35
percent of employers with 500 or more employees and 15 percent of
employers surveyed with fewer than 500 employees removed limits on the
number of allowed office visits or dollar limits in response to parity
requirements.
Several experts with whom we spoke told us that it was common for
employers to eliminate treatment limitations and annual or lifetime
dollar limits for MH/SU in response to parity requirements.[Footnote
34] For example, representatives from an insurance broker organization
and a trade association told us that employers with which they
interacted removed limits on the number of allowed office visits for
mental health conditions from their plans. A representative from a
large insurance company told us that the employers with whom they work
removed all limits on the number of allowed inpatient hospital days
from plans to which MHPAEA applies, and a representative from an
insurance broker organization also reported that employers with whom
they consulted removed lifetime dollar limits on substance use
disorders from their plans.
Cost-Sharing:
Among employers who reported information on cost-sharing, copayments
and coinsurance amounts for office visits with in-network providers
generally stayed about the same, fluctuating minimally from 2008 to
the current plan year, while copayments and coinsurance amounts for
outpatient services with in-network providers decreased slightly from
2008 to the current plan year (see table 1).
Table 1: Average Cost-Sharing for In-Network Office Visits and
Outpatient Services in the 2008 Plan Year and in the Current Plan Year:
Response: Office visit copayment;
Mental health conditions: 2008: $25;
Mental health conditions: Current plan year: $26;
Substance use disorders: 2008: $25;
Substance use disorders: Current plan year: $27.
Response: Office visit coinsurance;
Mental health conditions: 2008: 21%;
Mental health conditions: Current plan year: 19%;
Substance use disorders: 2008: 22%;
Substance use disorders: Current plan year: 19%.
Response: Outpatient services copayment;
Mental health conditions: 2008: $39;
Mental health conditions: Current plan year: $33;
Substance use disorders: 2008: $39;
Substance use disorders: Current plan year: $33.
Response: Outpatient services coinsurance;
Mental health conditions: 2008: 24%;
Mental health conditions: Current plan year: 19%;
Substance use disorders: 2008: 26%;
Substance use disorders: Current plan year: 19%.
Source: GAO employer survey of mental health and substance use
coverage.
Note: The calculations for the 2008 plan year are based on 123
employer responses and the calculations for the employer's current
plan year--either 2011 or 2010--are based on 130 employer responses.
[End of table]
Mercer's 2010 National Survey of Employer-Sponsored Health Plans found
that 3 percent of employers surveyed decreased their cost-sharing
requirements for MH/SU in response to MHPAEA, and larger employers
were more likely to change their cost-sharing requirements than
smaller employers. Specifically, according to Mercer, 20 percent of
employers with 20,000 or more employees and 6 percent of employers
with 500 to 999 employees reported decreasing their MH/SU copayments
or coinsurance to comply with MHPAEA.
Employers May Continue to Modify Benefits as Agencies Refine Parity
Requirements:
Employers may continue to modify certain nonfinancial requirements--
such as changes to the services they cover (the scope of services)
[Footnote 35] and NQTLs--in their MH/SU benefits in response to
agencies' issuance of final implementing regulations for MHPAEA.
Agency officials reported that the final regulations may provide
additional detail on the required scope of services and on using NQTLs.
Scope of Services:
The IFR does not specifically address the scope of services offered
within each classification of benefits,[Footnote 36] and agency
officials recognize that achieving parity in coverage is complicated
by the fact that not all treatments or treatment settings for MH/SU
correspond well to those for medical/surgical. Some commenters
requested clarification about whether an employer would be required to
cover a particular treatment or treatment setting for a mental health
condition or substance use disorder that is otherwise covered in a
plan, if benefits for the treatment or treatment settings are not
provided for medical/surgical conditions--for example, counseling, an
outpatient service used for treatment of MH/SU but not medical/
surgical. As part of its issuance of the IFR, the agencies requested
public comments on whether, and to what extent, the final regulations
should address the scope of services provided by a group health plan
or health insurance coverage. Agency officials from HHS's Office of
the Assistant Secretary for Planning and Evaluation (ASPE) and DOL are
conducting research on the costs to employers that are associated with
scope of services for MH/SU and intend to use the results to inform
potential final regulations on the issue.
Experts reported that some employers are unclear what types of
services for MH/SU they must offer within the IFR's six
classifications to be in compliance with MHPAEA and its implementing
regulations. These employers may modify their MH/SU benefits in
response to the final regulations.
Nonquantitative Treatment Limitations:
As part of the process of developing final regulations, DOL, HHS, and
Treasury are researching NQTLs for MH/SU, including convening a panel
of experts to discuss how health plans use NQTLs--for example, use of
pre-authorization for MH/SU benefits within certain classifications,
as compared to use of pre-authorization for medical/surgical benefits
within the same classification. The agencies may use this research to
provide more detailed guidelines on how NQTLs for MH/SU services can
be used on par with NQTLs used for medical/surgical services.
Currently, the IFR does not specify the steps employers can take to
achieve parity with NQTLs across classifications for coverage of MH/SU
and medical/surgical services. For example, the IFR generally requires
that any processes or other factors used in applying the NQTLs should
be "comparable to" and used "no more stringently" for MH/SU benefits
in a certain classification than they are for medical/surgical
benefits at that same classification, but these qualitative terms may
be interpreted or applied inconsistently by employers.[Footnote 37]
A representative from an MBHO told us that the IFR requirements for
NQTLs could be interpreted in different ways, and the MBHO has seen
variation in how employers are applying NQTLs in their plans.
Representatives from an advocacy group reported that, in some cases,
employers appear to be applying NQTLs more stringently to MH/SU
benefits than to medical/surgical benefits. For example, according to
the advocacy group, some plans require pre-authorization for inpatient
care for MH/SU services for every 2-day period the care is expected to
be given, but require pre-authorization for inpatient services for
medical/surgical benefits less frequently.[Footnote 38] The final
regulations, which will be informed by the agencies' findings, may
result in employers' further modification of their use of NQTLs in
their benefit packages in order to comply with any new or modified
requirements.
Research Suggests That Coverage for Mental Health Conditions and
Substance Use Disorders Has a Varied Effect on Enrollees:
Research indicates that enhanced coverage for MH/SU has generally led
to reduced enrollee expenditures. Research also indicates that health
insurance coverage for MH/SU has had mixed effects on access to, and
use of, MH/SU services. In addition, little research has explored the
effect of health insurance coverage for MH/SU on health status.
Research Indicates That Enhanced Health Insurance Coverage for Mental
Health Conditions and Substance Use Disorders Reduces Enrollee
Expenditures:
Of the nine studies we reviewed that focused on the effect of health
insurance coverage for MH/SU on enrollee expenditures, six studies
generally found that the implementation of parity requirements led to
reduced enrollee expenditures.[Footnote 39] Specifically, four of the
nine studies examined mental health parity requirements in the Federal
Employees Health Benefits Program (FEHBP) and found that implementing
parity resulted in reductions in enrollee out-of-pocket costs. For
example, one of these studies compared specific MH/SU benefits offered
in FEHBP plans before and after the implementation of parity, and
found that copayments and coinsurance for MH/SU services decreased by
50 percent or more after parity was implemented.[Footnote 40] Two of
the nine studies examined the impact of state parity laws on
expenditures and found that parity generally reduced enrollee
expenditures.[Footnote 41] For example, one of these studies found
that families with children in need of mental health services in
parity states were more likely to have lower annual out-of-pocket
costs than families with children in need of mental health services in
nonparity states.[Footnote 42]
Three of the nine studies examined other aspects of how health
insurance coverage for MH/SU may impact enrollee expenditures that
were unique to the scenarios or targeted populations studied. For
example, one study examined differences in out-of-pocket spending
among various populations and found that among individuals who use
mental health services, out-of-pocket expenses were highest for those
who were uninsured or enrolled in Medicare, compared with those who
had private health insurance or were enrolled in Medicaid.[Footnote 43]
Research Found Mixed Effects on Access to, and Use of, Services for
Mental Health Conditions and Substance Use Disorders:
Available research on access to, and use of, MH/SU services, as
affected by health insurance coverage, was mixed. Of the 30 studies we
reviewed on these topics, 17 studies found health insurance coverage
for MH/SU--or enhanced insurance coverage through parity requirements--
had some effect on access to, or use of, MH/SU services, whereas 13
studies found little to no effect.[Footnote 44]
Of the 17 studies finding some effect of health insurance coverage on
access to, or use of, MH/SU services:
* Six studies looked at a specific aspect of health insurance
coverage--cost-sharing requirements, pre-authorization requirements,
or the way MH/SU benefits are structured--and found that restricting
coverage had a negative effect on enrollees' use of services.
Specifically, one study found that as cost-sharing increased among
privately insured patients, the rate of substance use disorder
treatment decreased.[Footnote 45] Another study found that when health
plans increased the number of treatment sessions approved at a time,
patients were less likely to prematurely terminate treatment.[Footnote
46] A third study found that as private health plans increased the use
of managed care mechanisms, such as utilization review and prior
authorization, children decreased their use of MH/SU services.
[Footnote 47]
* Five studies indicated that plans with more comprehensive coverage
were associated with a positive effect on access to, or use of, MH/SU
services. For example, one study examined a large U.S.-based company
that reduced copayments and made efforts to destigmatize mental
illness, and found that the benefit design change led to an 18 percent
increase in the probability of enrollees initiating mental health
treatment.[Footnote 48]
* Four studies examined the effect of state parity requirements and,
as a group, found a mixed effect on enrollees' access to, or use of,
MH/SU services. For example, one of these studies examined the effect
of a state parity requirement within the first 3 years following
implementation of parity requirements, and found that the
implementation of parity requirements resulted in increased access to,
and use of, mental health services; however, the implementation of
parity resulted in reduced access to substance use disorder services.
[Footnote 49] Another study found that state parity requirements
increased access to, or use of, MH/SU services for individuals with
mild to moderate mental health needs, but that state parity
requirements had no effect on access to, or use of, MH/SU services for
individuals with severe mental health needs.[Footnote 50] The
remaining two studies found that state parity requirements increased
access to, or use of, MH/SU services.[Footnote 51]
* Two studies found that being uninsured or having a certain type of
insurance was associated with lower access to MH/SU services.[Footnote
52] For example, one study assessed the extent to which psychiatrists
were accepting new patients with different types of insurance--
Medicaid, Medicare, and private insurance--and with different types of
care plans.[Footnote 53] This study found that psychiatrists were less
likely to accept new patients in managed care plans and Medicaid than
patients in nonmanaged private insurance plans and Medicare,
indicating that the type of coverage patients have may affect their
access to available providers.[Footnote 54]
In contrast, 13 of the 30 studies we reviewed found little to no
effect:
* Three studies examined the effect of mental health parity
requirements in the FEHBP and found that enhanced coverage did not
increase access to, or use of, MH/SU services.
* Six studies examined the effect of state mental health parity
requirements on access to, or use of, MH/SU services and found little
to no effect. One of these studies found a difference in the effect of
state mental health parity requirements by employer size.
Specifically, after implementation of state mental health parity
requirements, enrollees from smaller employers--comprised of 50 to 100
employees--increased the use of mental health services after parity,
while there was little or no effect on the use of mental health
services for enrollees from larger employers--comprised of 100 or more
employees.[Footnote 55]
* Four studies focused on the effect of health insurance coverage on
access to, or use of, MH/SU services for a specific population, and
also found that health insurance coverage had little to no effect on
access to, or use of, MH/SU services. For example, two studies
examined the effect of health insurance coverage on specific
populations--children with special mental health service needs living
in a rural area, or low-income, minority groups--and found that having
private health insurance had little to no effect on use of services
for either of these populations.[Footnote 56]
Little Research Has Explored the Relationship between Health Insurance
Coverage and Health Status:
Of the studies we reviewed, two studies examined the effect of health
insurance coverage for MH/SU on health status of the general
population. One study compared suicide rates among states with
different parity requirements and found that state mandates did not
have an effect on suicide rates.[Footnote 57] The other study found
that increasing copayments was associated with an increased likelihood
of the reoccurrence of substance use treatment. Specifically, each 10
percent increase in copayment was associated with a 1 percent increase
in the probability of returning to begin a new course of substance use
disorder treatment within 180 days.[Footnote 58]
Agency Comments:
DOL and HHS reviewed a draft of this report and provided technical
comments, which we incorporated as appropriate.
We are sending copies of this report to the Secretaries of the
Department of Labor and the Department of Health and Human Services
and appropriate congressional committees. In addition, the report will
be available at no charge on GAO's website at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions regarding this report, please
contact me at (202) 512-7114 or dickenj@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made key contributions
to this report are listed in appendix III.
Signed by:
John E. Dicken:
Director, Health Care:
List of Committees:
The Honorable Max Baucus:
Chairman:
The Honorable Orrin Hatch:
Ranking Member:
Committee on Finance:
United States Senate:
The Honorable Tom Harkin:
Chairman:
The Honorable Michael B. Enzi:
Ranking Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable John Kline:
Chairman:
The Honorable George Miller:
Ranking Member:
Committee on Education and the Workforce:
House of Representatives:
The Honorable Fred Upton:
Chairman:
The Honorable Henry Waxman:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Dave Camp:
Chairman:
The Honorable Sander Levin:
Ranking Member:
Committee on Ways and Means:
House of Representatives:
[End of section]
Appendix II: Scope and Methodology:
To determine the extent to which employers cover mental health
conditions and substance use disorders (MH/SU) both currently and in
2008, we surveyed a stratified random sample of small, medium, large,
and very large employers about the MH/SU covered in their most popular
health plans for the most current plan year--either in 2011 or 2010--
as well as for 2008. We defined most popular health plan as the plan
that covered the greatest number of lives. We fielded a web-based
survey between May 18, 2011, and July 1, 2011, to 707 employers,
selected from a sampling frame we developed using the Lexis Nexis
corporate database.[Footnote 59]
Our survey was designed to collect information about trends in
employer coverage of MH/SU benefits, and included questions about
coverage for MH/SU in the most current plan year--2011 or 2010--and in
2008. We conducted a survey of employers because we were unable to
identify a published national employer survey that included specific
detailed information about employers' MH/SU benefits prior to and
following MHPAEA--namely, information about diagnoses included in or
excluded from coverage. For our survey, employers had the option of
either completing the entire survey, including detailed questions
about their most popular health plans' cost-sharing requirements, or
completing a portion of the survey and submitting to us their most
popular health plans' summary plan documents (SPD), which included
information on the plans' cost-sharing requirements.[Footnote 60]
As part of the survey development process, we asked experts to review
a draft version of the survey and we pretested the survey. We
incorporated feedback from experts and the pretests into the survey.
We selected a stratified random sample of 1,000 employers from our
sampling frame. Our stratification divided employers into groups based
on the number of employees--small employers had 51-199 employees;
medium employers had 200-999 employees; large employers had 1,000-
4,999 employees; and very large employers had 5,000 or more employees.
[Footnote 61] We obtained working e-mail addresses for 707 employers,
which received the survey on May 18, 2011. The distribution of
employer sizes among the final group of employers was similar to that
in the original sample.
When we closed the survey on July 1, 2011, after following up with
nonrespondents by phone and e-mail to encourage their participation,
168 employers had submitted usable survey responses, for a response
rate of 24 percent. Given the response rate, our survey results are
not generalizable. Rather, the survey responses provide information
limited to responding employers' coverage of MH/SU in the current plan
year and 2008 plan year. Specifically, we received usable survey
responses from 91 small employers, 50 medium employers, 19 large
employers, and 8 very large employers. All 168 employers offered
coverage of mental health conditions, substance use disorders, or
both, in either the current plan year, 2008 plan year, or both plan
years. We expected all employers to respond to a key set of questions;
however, not every employer that responded to our survey answered the
key questions in their entirety. In addition, our survey included a
series of detailed benefits questions which employers were expected to
respond to only if the question applied to them.[Footnote 62] For all
the survey questions to which we expected a response, the percentage
of employers that did not respond to a question ranged from zero to 46
percent, depending on the question. We did not verify the accuracy of
the employers' responses or assess compliance with MHPAEA.
Of the 168 employers that provided usable survey responses, 130
employers answered at least one of the detailed benefits questions--
detailed survey questions about the limitations and cost-sharing
requirements of their MH/SU benefits--for the current plan year, and
123 employers answered at least one of the detailed benefits questions
for the 2008 plan year. As a result, when we analyzed the total survey
data, we used 168 as the denominator for our calculations. However, we
used 130 as the denominator for our calculations for responses to the
detailed benefits questions for the current plan year, and used 123 as
the denominator for our calculations for responses to the detailed
benefits questions for the 2008 plan year. In instances where we
analyzed responses from a smaller number of respondents, we noted this
in the text.
To supplement the data collected from our survey, we reviewed the
results of published national employer surveys from the Kaiser Family
Foundation and Health Research and Educational Trust (Kaiser/HRET) and
Mercer. These surveys provided generalizable information on employers'
coverage of MH/SU.
Since 1999, Kaiser/HRET has surveyed a sample of employers each year
through telephone interviews with human resource and benefits managers
and published the results in its annual report--Employer Health
Benefits. Kaiser/HRET selects a random sample from a Survey Sampling
International list of private employers and from the Census Bureau's
Census of Governments list of public employers with three or more
employees. Kaiser/HRET then stratifies the sample by industry and
employer size. It attempts to repeat interviews with employers that
responded in prior years. For the most recently completed annual
survey--conducted from January to May 2010 and published in September
2010--2,046 employers responded to the full survey, giving the survey
a 47 percent response rate.[Footnote 63] Using statistical weights,
Kaiser/HRET projected its results nationwide. Kaiser/HRET used the
following definitions for employer size: (1) small--3 to 199
employees--and (2) large--200 and more employees. In some cases,
Kaiser/HRET reported information for additional categories of small
and large employer sizes.
Since 1993, Mercer has surveyed a stratified random sample of
employers each year through mail questionnaires and telephone
interviews and published the results in its annual report--National
Survey of Employer-Sponsored Health Plans. Mercer selects a random
sample of private sector employers from a Dun & Bradstreet database,
stratified into eight categories, and randomly selects public sector
employers--state, county, and local governments--from the Census of
Governments. The random sample of private sector and government
employers represents employers with 10 or more employees. For the 2010
survey, which was published in 2011, Mercer mailed questionnaires to
employers with 500 or more employees in July 2010 along with
instructions for accessing a web-based version of the survey
instrument, another option for participation.[Footnote 64] Employers
with fewer than 500 employees, which historically have been less
likely to respond using a paper questionnaire, were contacted to be
given the option of responding to the survey by phone or by using the
web-based survey. Telephone follow-up was conducted with employers
with 500 or more employees in the random sample and some mail and web
respondents were contacted by phone to clear up inconsistent or
incomplete data. A total of 2,833 employers responded to the survey.
By using statistical weights, Mercer projected its results nationwide
and for four geographic regions. The Mercer survey report contains
information for large employers--500 or more employees--and for
categories of large employers with certain numbers of employees as
well as information for small employers--those with fewer than 500
employees. Mercer used the same methodology for its 2008 survey, which
was published in 2009.[Footnote 65] A total of 2,873 employers
responded to the survey. According to a Mercer representative, in any
given year, Mercer typically obtains a 25 percent response rate to its
survey.
We conducted interviews with agency officials and experts to learn
about the implementation of MHPAEA and trends in employers' coverage
of MH/SU benefits. We spoke with agency officials from the Department
of Labor (DOL), Department of Health and Human Services's (HHS)
Assistant Secretary for Planning and Evaluation (ASPE), and HHS's
Substance Abuse and Mental Health Services Administration who had
expertise in MH/SU issues. We did not interview Treasury officials
because the focus of this engagement did not relate to that agency's
scope of responsibility. We spoke with experts who included
representatives from two large managed behavioral health organizations
(MBHO); two large national insurance companies; mental health advocacy
organizations; institutions that field employer-based surveys on
health insurance coverage; a large benefits consulting firm; an
insurance broker organization; and three trade associations. We also
interviewed four employer survey respondents--one in each employer
size category--to obtain more detailed information about the
employers' coverage of MH/SU, and their reasons for making or not
making changes to coverage after the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) took
effect.
For our literature review on the effect of health insurance coverage
for MH/SU on enrollees' health care expenditures,[Footnote 66] access
to, or use of, MH/SU services, and health status, we conducted a key
word search of nine databases, such as Medline and EMBASE, that
included peer-reviewed journals and other periodicals to capture
articles published between January 1, 2000, and March 11, 2011. We
searched these databases for articles with key words in their title or
article subject terms related to the effect of health insurance on
health care expenditures or health status,[Footnote 67] using
combinations and variations of the words "insurance coverage," "mental
health," "substance use," "health cost," "health expenditure," and
"health status." From these sources, we identified 246 abstracts of
research articles, publications, and reports.
After reviewing the abstracts, we included 34 studies that discussed
the effect of health insurance coverage on enrollee expenditures,
access to, or use of, MH/SU services, or health status. We also
included articles in our literature review that were suggested to us
by the experts we interviewed, as well as those that were referenced
in the articles found during our initial search.
[End of section]
Appendix III: Articles Reviewed on the Effect of Health Insurance
Coverage on Enrollees:
We conducted a review of published studies between January 2000 and
March 11, 2011, that included an assessment of the effect of health
insurance coverage for mental health conditions and substance use
disorders (MH/SU) on enrollee expenditures, access to, or use of,
MH/SU services, or health status.[Footnote 68] We identified 34 such
studies, 9 of which addressed the effect of health insurance coverage
on enrollee expenditures, 30 of which discussed access to, or use of,
MH/SU services, and 2 of which discussed health status. Some studies
addressed more than one topic.
Tables 2 through 4 identify the 34 studies included in our review, and
whether we determined them to be relevant to the effect of health
insurance coverage for MH/SU on enrollees' health care expenditures,
access to, or use of, MH/SU services, or health status.
Table 2: Studies Published between January 2000 and March 11, 2011,
Addressing the Effect of Health Insurance Coverage for Mental Health
Conditions and Substance Use Disorders on Enrollees' Health Care
Expenditures:
Enrollee expenditures:
Azrin, Susan T., Haiden A. Huskamp, Vanessa Azzone, Howard H. Goldman,
Richard G. Frank, M. Audrey Burnam, Sharon-Lise T. Normand, et al.,
"Impact of Full Mental Health and Substance Abuse Parity for Children
in the Federal Employees Health Benefits Program." Pediatrics, vol.
119, no. 2 (2007): e452-e459.
Azzone, Vanessa, Richard G. Frank, Sharon-Lise T. Normand and M.
Audrey Burnam, "Effect of Insurance Parity on Substance Abuse
Treatment." Psychiatric Services, vol. 62, no. 2 (2011): 129-34.
Barry, Colleen L. and Susan H. Busch, "Do State Parity Laws Reduce the
Financial Burden on Families of Children with Mental Health Care
Needs?" Health Services Research, vol. 42, no.3 (2007): 1061-84.
Barry, Colleen L. and M. Susan Ridgely, "Mental Health and Substance
Abuse Insurance Parity for Federal Employees: How Did Health Plans
Respond?" Journal of Policy Analysis and Management, vol. 27 (2008):
155-70.
Goldman, Howard H., Richard G. Frank, M. Audrey Burnam, Haiden A.
Huskamp, M. Susan Ridgely, Sharon-Lise T. Normand, Alexander S. Young,
et al., "Behavioral Health Insurance Parity for Federal Employees."
The New England Journal of Medicine, vol. 354, no. 13 (2006): 1378-86.
Grazier, Kyle L. and Harold Pollack, "Translating Behavioral Health
Services Research into Benefits Policy." Medical Care Research and
Review, vol. 57, supplement 2 (2000): 53-71.
Lo Sasso, Anthony T., Ithai Z. Lurie, Jhee Un Lee and Richard C.
Lindrooth, "The Effects of Expanded Mental Health Benefits on
Treatment Costs." The Journal of Mental Health Policy and Economics,
vol. 9 (2006): 25-33.
Ringel, Jeanne S. and Roland Sturm, "Financial Burden and Out-of-
Pocket Expenditures for Mental Health Across Different Socioeconomic
Groups: Results from HealthCare for Communities." The Journal of
Mental Health Policy and Economics, vol. 4 (2001): 141-50.
Rosenbach, Margo, Tim Lake, Cheryl Young, Wendy Conroy, Brian Quinn,
Julie Ingels, Brenda Cox, et al., Effects of the Vermont Mental Health
and Substance Abuse Parity Law. A special report prepared at the
request of the Substance Abuse and Mental Health Services
Administration, U.S. Department of Health and Human Services. 2003.
Source: GAO's review of published studies.
[End of table]
Table 3: Studies Published between January 2000 and March 11, 2011,
Addressing the Effect of Health Insurance Coverage for Mental Health
Conditions and Substance Use Disorders on Enrollees' Access to, or Use
of, MH/SU Services:
Access to, or use of, MH/SU services:
Azrin, Susan T., Haiden A. Huskamp, Vanessa Azzone, Howard H. Goldman,
Richard G. Frank, M. Audrey Burnam, Sharon-Lise T. Normand, et al.,
"Impact of Full Mental Health and Substance Abuse Parity for Children
in the Federal Employees Health Benefits Program." Pediatrics, vol.
119, no. 2 (2007): e452-e459.
Azzone, Vanessa, Richard G. Frank, Sharon-Lise T. Normand and M.
Audrey Burnam, "Effect of Insurance Parity on Substance Abuse
Treatment." Psychiatric Services, vol. 62, no. 2 (2011): 129-34.
Bao, Yuhua and Roland Sturm, "The Effects of State Mental Health
Parity Legislation on Perceived Quality of Insurance Coverage,
Perceived Access to Care, and Use of Mental Health Specialty Care."
Health Services Research, vol. 39, no. 5 (2004): 1361-77.
Barry, Colleen L. and Susan H. Busch, "Caring for Children with Mental
Disorders: Do State Parity Laws Increase Access to Treatment?" The
Journal of Mental Health Policy and Economics, vol. 11 (2008): 57-66.
Barry, Colleen L. and Susan H. Busch, "Do State Parity Laws Reduce the
Financial Burden on Families of Children with Mental Health Care
Needs?" Health Services Research, vol. 42, no.3 (2007): 1061-84.
Busch, Susan H. and Colleen L. Barry, "New Evidence on the Effects of
State Mental Health Mandates." Inquiry, vol. 45 (2008): 308-22.
Ciemins, Elizabeth L., "The Effect of Parity-Induced Copayment
Reductions on Adolescent Utilization of Substance Use Services."
Journal of Studies on Alcohol, vol. 65 (2004): 731-5.
Costello, E. Jane, William Copeland, Alexander Cowell and Gordon
Keeler, "Service Costs of Caring for Adolescents with Mental Illness
in a Rural Community, 1993-2000." The American Journal of Psychiatry,
vol. 164 (2007): 36-42.
Dave, Dhaval and Swati Mukerjee, "Mental Health Parity Legislation,
Cost-Sharing and Substance-Abuse Treatment Admissions." Health
Economics, vol. 20 (2011): 161-83.
Goldman, Howard H., Richard G. Frank, M. Audrey Burnam, Haiden A.
Huskamp, M. Susan Ridgely, Sharon-Lise T. Normand, Alexander S. Young,
et al., "Behavioral Health Insurance Parity for Federal Employees."
The New England Journal of Medicine, vol. 354, no. 13 (2006): 1378-86.
Grazier, Kyle L. and Harold Pollack, "Translating Behavioral Health
Services Research into Benefits Policy." Medical Care Research and
Review, vol. 57, supplement 2 (2000): 53-71.
Harris, Katherine M. Christopher Carpenter and Yuhua Bao, "The Effects
of State Parity Laws on the Use of Mental Health Care." Medical Care,
vol. 44, no. 6 (2006): 499-505.
Leslie, Douglas L., Robert A. Rosenheck and Sarah McCue Horwitz,
"Patterns of Mental Health Utilization and Costs Among Children in a
Privately Insured Population." Health Services Research, vol. 36, no.1
(2001): 113-27.
Lindrooth, Richard C., Anthony T. Lo Sasso and Ithai Z. Lurie, "The
Effect of Expanded Mental Health Benefits on Treatment Initiation and
Specialist Utilization." Health Services Research, vol. 40, no. 4
(2005): 1092-1107.
Liu, Xiaofeng, Roland Sturm, and Brian J. Cuffel, "The Impact of Prior
Authorization on Outpatient Utilization in Managed Behavioral Health
Plans." Medical Care Research and Review, vol. 57, no. 2 (2000): 182-
195.
Lo Sasso, Anthony T., Richard C. Lindrooth, Ithai Z. Lurie and John S.
Lyons, "Expanded Mental Health Benefits and Outpatient Depression
Treatment Intensity." Medical Care, vol. 44, no. 4 (2006): 366-72.
Lo Sasso, Anthony T., Ithai Z. Lurie, Jhee Un Lee and Richard C.
Lindrooth, "The Effects of Expanded Mental Health Benefits on
Treatment Costs." The Journal of Mental Health Policy and Economics,
vol. 9 (2006): 25-33.
Lo Sasso, Anthony T. and John S. Lyons, "The Sensitivity of Substance
Abuse Treatment Intensity to Co-payment Levels," The Journal of
Behavioral Health Services and Research, vol. 31 (2004): 50-65.
Lu, Chunling, Richard G. Frank and Thomas G. McGuire, "Demand Response
of Mental Health Services to Cost Sharing under Managed Care." The
Journal of Mental Health Policy and Economics, vol. 11 (2008): 113-25.
Pacula, Rosalie Liccardo and Roland Sturm, "Mental Health Parity: Much
Ado about Nothing?" Health Services Research, vol. 35 (2000): 263-275.
Rosenbach, Margo, Tim Lake, Cheryl Young, Wendy Conroy, Brian Quinn,
Julie Ingels, Brenda Cox, et al., Effects of the Vermont Mental Health
and Substance Abuse Parity Law. A special report prepared at the
request of the Substance Abuse and Mental Health Services
Administration, U.S. Department of Health and Human Services. 2003.
Schmidt, Laura A. and Constance M. Weisner, "Private Insurance and the
Utilization of Chemical Dependency Treatment." Journal of Substance
Abuse Treatment, vol. 28 (2005): 67-76.
Stein, Bradley D. and Weiying Zhang, "Drug and Alcohol Treatment Among
Privately Insured Patients: Rate of Specialty Substance Abuse
Treatment and Association with Cost-Sharing." Drug and Alcohol
Dependence, vol. 71 (2003): 153-59.
Stein, Bradley, Maria Orlando and Roland Sturm, "The Effect of
Copayments on Drug and Alcohol Treatment Following Inpatient
Detoxification Under Managed Care." Psychiatric Services, vol. 51, no.
2 (2000): 195-198.
Sturm, Roland, "State Parity Legislation and Changes in Health
Insurance and Perceived Access to Care Among Individuals with Mental
Illness: 1996-1998." The Journal of Mental Health Policy and
Economics, vol. 3 (2000): 209-213.
Thomas, Kathleen C. and Lonnie R. Snowden, "Minority Response to
Health Insurance Coverage for Mental Health Services." The Journal of
Mental Health Policy and Economics, vol. 4 (2001): 35-41.
Weisner, Constance, Helen Matzger, Tammy Tam and Laura Schmidt, "Who
Goes to Alcohol and Drug Treatment? Understanding Utilization Within
the Context of Insurance." Journal of Studies on Alcohol, vol. 63
(2002): 673-682.
Wells, Kenneth B., Cathy Donald Sherbourne, Roland Sturm, Alexander S.
Young and M. Audrey Burnam, "Alcohol, Drug Abuse, and Mental Health
Care for Uninsured and Insured Adults." Health Services Research, vol.
37, no. 4 (2002): 1055-66.
Wilk, Joshua E., Joyce C. West, William E. Narrow, Donald S. Rae and
Darrel A. Regier, "Access to Psychiatrists in the Public Sector and in
Managed Health Plans." Psychiatric Services, vol. 56, no. 4 (2005):
408-10.
Zuvekas, Samuel H., Agnes E. Rupp and Grayson S. Norquist, "The
Impacts of Mental Health Parity and Managed Care in One Large
Employer: a Reexamination." Health Affairs, vol. 24, no. 6 (2005):
1668-71.
Source: GAO's review of published studies.
[End of table]
Table 4: Studies Published between January 2000 and March 11, 2011,
Addressing the Effect of Health Insurance Coverage for Mental Health
Conditions and Substance Use Disorders on Enrollees' Health Status:
Health status:
Klick, Jonathan and Sara Markowitz, "Are Mental Health Insurance
Mandates Effective? Evidence From Suicides." Health Economics, vol. 15
(2006): 83-97.
Lo Sasso, Anthony T. and John S. Lyons, "The Effects of Copayments on
Substance Abuse Treatment Expenditures and Treatment Reoccurrence."
Psychiatric Services, vol. 53, no.12 (2002): 1605-11.
Source: GAO's review of published studies.
[End of table]
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
John E. Dicken, (202) 512-7114, dickenj@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Jennifer Grover, Assistant
Director; Martha Kelly, Assistant Director; Elizabeth Conklin;
Jennifer DeYoung; Carolyn Fitzgerald; Giao N. Nguyen; Laurie Pachter;
Monica Perez-Nelson; and Rachel Schulman made key contributions to
this report.
[End of section]
Related GAO Products:
Private Health Insurance: Waivers of Restrictions on Annual Limits on
Health Benefits. [hyperlink, http://www.gao.gov/products/GAO-11-725R].
Washington, D.C.: June 14, 2011.
Private Health Insurance: Access to Individual Market Coverage May Be
Restricted for Applicants with Mental Disorders. [hyperlink,
http://www.gao.gov/products/GAO-02-339]. Washington, D.C.: February
28, 2002.
Mental Health: Community-Based Care Increases for People with Serious
Mental Illness. [hyperlink, http://www.gao.gov/products/GAO-01-224].
Washington, D.C.: December 19, 2000.
Mental Health Parity Act: Employers' Mental Health Benefits Remain
Limited Despite New Federal Standards. [hyperlink,
http://www.gao.gov/products/GAO/T-HEHS-00-113]. Washington, D.C.: May
18, 2000.
Mental Health Parity Act: Despite New Federal Standards, Mental Health
Benefits Remain Limited. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-95]. Washington, D.C.: May 10,
2000.
[End of section]
Footnotes:
[1] National Institute of Mental Health, "Statistics: Any Disorder In
Adults Among Adults," NIMH Statistics (Bethesda, Md.: July 29, 2010),
accessed September 14, 2011, [hyperlink,
http://nimh.nih.gov/statistics/1ANYDIS_ADULT.shtml].
[2] Substance Abuse and Mental Health Services Administration, Results
from the 2010 National Survey on Drug Use and Health: Summary of
National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-
4658 (Rockville, Md.: September 2011).
[3] NIMH, "Use of Mental Health Services and Treatment Among Adults,"
NIMH Statistics (Bethesda, Md.: July 29, 2010), accessed September 7,
2011, [hyperlink,
http://www.nimh.nih.gov/statistics/3USE_MT_ADULT.shtml].
[4] Agency for Healthcare Research and Quality, "Hospital Stays
Related to Mental Health, 2006," Healthcare Cost and Utilization
Project Statistical Brief #62 (Rockville, Md.: October 2008).
[5] Substance Abuse and Mental Health Services Administration, Results
from the 2010 National Survey on Drug Use and Health: Summary of
National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-
4658 (Rockville, Md.: September 2011).
[6] Pub. L. No. 110-343, Div. C, Tit. V, Sub. B, §§ 511-512, 122 Stat.
3765, 3881-3893 (Oct. 3, 2008). MHPAEA, passed as part of the
Emergency Economic Stabilization Act of 2008, expands the parity
requirements established by the Mental Health Parity Act of 1996 (Pub.
L. No. 104-204, Tit. VII, §§ 701-702, 100 Stat. 2874, 2944-2950 (Sept.
26, 1996), the first federal mental health parity law, which required
parity in annual and aggregate lifetime dollar limits. MHPAEA expanded
the 1996 federal parity requirements to include parity more broadly in
financial requirements (including cost-sharing requirements),
treatment limitations, and in-and out-of-network covered benefits.
MHPAEA also requires parity for substance use disorder benefits.
[7] Generally, MHPAEA requires that financial requirements and
treatment limitations imposed on MH/SU cannot be more restrictive than
the predominant financial requirements and treatment limitations that
apply to substantially all medical/surgical benefits. MHPAEA also
applies to Medicaid managed care, Children's Health Insurance
Programs, and certain plans sponsored by state and local governments.
Employers with 50 or fewer employees are exempt from the law. MHPAEA
does not apply to individual health insurance plans. In addition, each
year employers sponsoring group health plans can file for a 1-year
exemption from MHPAEA requirements if the health plan's total costs--
medical/surgical and MH/SU combined--increase by at least 1 percent (2
percent in the first year of implementing parity) and if those costs
are solely attributable to parity. Since the legislation applies to
group health plans and group health plans are primarily offered by
employers, this report focuses on group health plans--or health
insurance coverage offered in connection with such a plan--sponsored
by employers. We therefore refer to group health plan sponsors
responsible for compliance with MHPAEA as employers.
[8] To develop our sampling frame, we used the Dossier function of the
Lexis Nexis corporate database to select 32,431 U.S.-based companies
on January 18, 2011. We selected privately held and publicly traded
parent companies with between 51 to 100,000 employees that were
headquartered in the United States. We drew our random sample of
employers from this sampling frame. We excluded employers from our
survey that had 50 or fewer employees because MHPAEA did not apply to
them.
[9] Unless otherwise specified, these studies examined the effect of
health insurance coverage for MH/SU in general and were not specific
to examining the effects of federal or state parity laws, including
MHPAEA.
[10] Benefits are provisions or services included in a health
insurance plan's coverage.
[11] A plan year refers to the 12-month period during which yearly
plan design features such as the deductible, out-of-pocket maximum,
and specific benefit maximums accumulate. A plan year is often, but
not always, January 1 through December 31.
[12] Within the coverage of MH/SU that employers may offer, the types
of MH/SU treatment services and the settings in which MH/SU treatment
services are provided vary widely, so that a patient may receive care
appropriate to the severity of the symptoms. Types of MH/SU services
can include: counseling, case management, partial hospitalization,
inpatient treatment, vocational rehabilitation, and a variety of
residential programs. MH/SU treatment may also include prescription
drugs. In addition, patients with acute symptoms may be treated by
personnel in emergency rooms and hospital units, and by MH/SU crisis
and outreach specialists. Patients with more subacute symptoms are
treated by personnel in hospitals, day treatment programs, mental
health center programs, and by different types of individual
practitioners. Patients with long-term symptoms are often treated in
mental health centers, residential units, and practitioners' offices.
[13] The Mental Health Parity Act of 1996 established requirements
with respect to lifetime and annual limits that were later
supplemented by MHPAEA, enacted in 2008. This report focuses on
MHPAEA's effects on parity and coverage.
[14] Out-of-network providers are providers not included in a group of
designated providers with whom the plan has an agreement to provide
care to enrollees--called in-network providers. Enrollees' costs are
generally lower if they obtain care from in-network providers, rather
than out-of-network providers.
[15] See GAO, Mental Health Parity Act: Despite New Federal Standards,
Mental Health Benefits Remain Limited, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-95] (Washington, D.C.: May 10,
2000).
[16] States may also pass laws requiring that mental health coverage
sold in the state be offered on par with medical/surgical, and these
requirements may be more stringent than those required by federal law.
According to the National Conference of State Legislatures, state
parity laws regulating mental health coverage have been passed in 49
states and the District of Columbia as of May 2011. See National
Conference of State Legislatures, "State Laws Mandating or Regulating
Mental Health Benefits" (Washington, D.C.: May 2011), accessed June
13, 2011, [hyperlink, http://www.ncsl.org/default.aspx?tabid=14352].
[17] Beginning in 2014, certain health plans will be required to offer
MH/SU coverage as part of the Patient Protection and Affordable Care
Act's essential health benefits requirements.
[18] 75 Fed. Reg. 5410 (Feb. 2, 2010).
[19] Conversely, quantitative treatment limitations are expressed
numerically and include number of covered outpatient office visits or
hospital days.
[20] Pre-authorization of services is the requirement that an enrollee
receives prior approval for care. Utilization review is the evaluation
of the use of hospital services, including the appropriateness of the
admission, length of stay, and ancillary services.
[21] However, this requirement allows variations to the extent that
recognized clinically appropriate standards of care may permit a
difference.
[22] Of the 168 employers that provided usable responses to our
survey, 160 employers responded to the survey question about offering
MH/SU for the current plan year and for the 2008 plan year. The
remaining 8 employers reported that they offered coverage for either
MH/SU or for mental health conditions only for the current year and
did not provide an answer about their coverage of MH/SU for the 2008
plan year.
[23] One employer that reported continuing to offer mental health
coverage in the current plan year enhanced its coverage by adding
substance use disorder coverage in the current plan year.
[24] Specifically, the survey found that of the 31 percent of
employers that made changes to their mental health benefits as a
result of MHPAEA, 5 percent reported eliminating coverage for MH/SU.
See Kaiser Family Foundation and the Health Research & Educational
Trust (Kaiser/HRET), Employer Health Benefits 2010 Annual Survey,
September 2010.
[25] Mercer, National Survey of Employer-Sponsored Health Plans: 2010
Survey Report (New York, N.Y.: Mercer, LLC, 2011), and Mercer,
National Survey of Employer-Sponsored Health Plans: 2008 Survey Report
(New York, N.Y.: Mercer, LLC, 2009).
[26] According to most employers that responded to our survey, the
Diagnostic and Statistical Manual of Mental Disorders is considered to
be the standard basis of their coverage for MH/SU. Experts also told
us that the Diagnostic and Statistical Manual of Mental Disorders is
the most commonly used basis of coverage for MH/SU. The Diagnostic and
Statistical Manual of Mental Disorders, fourth edition, lists 16 broad
diagnostic classes of MH/SU. Each of the 16 broad diagnostic classes
are comprised of subcategories. An example of a broad diagnostic class
would be Mood disorders, and a diagnosis subcategory within that class
would be Depressive disorders.
[27] Of the 168 employers that provided usable responses to our
survey, 67 employers responded to the survey question about which
diagnoses were included in the MH/SU benefits for both the current
plan year and 2008 plan year.
[28] Of the 168 employers that provided usable responses to our
survey, 67 employers responded to the survey question about which
diagnoses were included in the MH/SU benefits for both the current
plan year and 2008 plan year.
[29] Our survey asked employers to select from a list of 16 broad
diagnostic classes of MH/SU, those diagnostic classes for which the
company covered treatment in the current plan year and 2008 plan year.
[30] Of the 168 employers that provided usable responses to our
survey, 130 employers responded to the detailed benefits questions of
the survey for the current plan year, and 123 employers responded to
the detailed benefits questions of the survey for the 2008 plan year.
[31] Of the 168 employers that provided usable responses to our
survey, 96 employers responded to the question about whether the most
popular health plan for the current year excluded coverage for any
specific treatments related to MH/SU, and 81 employers responded to
this question for the 2008 plan year.
[32] Some of the reduction in lifetime dollar limits may be
attributable to employers' implementation of the Patient Protection
and Affordable Care Act, which prohibits lifetime limits on the dollar
value of essential health benefits, including MH/SU services for plan
years beginning on or after September 23, 2010. The act also requires
health insurers to phase-out annual limits on these benefits,
including MH/SU benefits, starting with plan years beginning on or
after September 23, 2010, with the elimination of annual limits
occurring with plan years that begin on January 1, 2014.
[33] Of the 168 employers that provided usable responses to our
survey, 130 employers responded to the detailed benefits questions of
the survey for the current plan year, and 123 employers responded to
the detailed benefits questions of the survey for the 2008 plan year.
[34] Our study did not address employers' compliance with MHPA's
lifetime and annual limit requirements.
[35] The scope of services--also known as the continuum of care--is
the types of services that a plan offers to treat a condition.
[36] The six classifications of benefits, as defined in the IFR, are
(1) inpatient, in-network; (2) inpatient, out-of-network; (3)
outpatient, in-network; (4) outpatient, out-of-network; (5) emergency
care; and (6) prescription drugs.
[37] Specifically, the IFR states that any processes, strategies,
evidentiary standards, or other factors used in applying the
nonquantitative treatment limitation to mental health or substance use
disorder benefits in a classification must be comparable to, and
applied no more stringently than, the processes, strategies,
evidentiary standards, or other factors used in applying the
limitation with respect to medical/surgical benefits in the
classification except to the extent that recognized clinically
appropriate standards of care may permit a difference. 75 Fed. Reg.
5410 (Feb. 2, 2010).
[38] Requiring more frequent pre-authorization can affect use of
services. According to a study on the impact of pre-authorization on
the use of mental health services, when an enrollee must obtain pre-
authorization more frequently for outpatient mental health treatments,
they are more likely to terminate treatment earlier. See X. Liu, et
al., "The Impact of Prior Authorization on Outpatient Utilization in
Managed Behavioral Health Plans," Medical Care Research and Review,
vol. 57, no. 2 (2000).
[39] Additionally, a recently published study examining the effect of
Oregon's parity requirements on expenditures for MH/SU services found
that increases in spending on MH/SU services after implementation of
Oregon's parity law were almost entirely the result of a general trend
observed among individuals with and without parity. See J.K.
McConnell, et al., "Behavioral Health Insurance Parity: Does Oregon's
Experience Presage the National Experience With the Mental Health
Parity and Addiction Equity Act?" American Journal of Psychiatry
(2011).
[40] C.L. Barry and M.S. Ridgely, "Mental Health and Substance Abuse
Insurance Parity for Federal Employees: How Did Health Plans Respond?"
Journal of Policy Analysis and Management, vol. 27 (2008).
[41] See C.L. Barry and S.H. Busch, "Do State Parity Laws Reduce the
Financial Burden on Families of Children with Mental Health Care
Needs?" Health Services Research, vol. 42, no. 3, Part I (2007), and
M. Rosenbach et al., Effects of the Vermont Mental Health and
Substance Abuse Parity Law. A special report prepared at the request
of the Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services, 2003.
[42] Barry and Busch, "Do State Parity Laws Reduce the Financial
Burden on Families of Children with Mental Health Care Needs?"
[43] J.S. Ringel and R. Sturm, "Financial Burden and Out-of-Pocket
Expenditures for Mental Health Across Different Socioeconomic Groups:
Results From HealthCare for Communities," The Journal of Mental Health
Policy and Economics, vol. 4 (2001).
[44] Some study authors have noted that several factors may affect
access to, or use of, MH/SU services, including the use of techniques
such as pre-authorization or utilization review, and stigma associated
with MH/SU that may prevent enrollees from seeking needed services.
[45] B.D. Stein and W. Zhang, "Drug and Alcohol Treatment Among
Privately Insured Patients: Rate of Specialty Substance Abuse
Treatment and Association with Cost-Sharing," Drug and Alcohol
Dependence, vol. 71 (2003).
[46] Liu et al., "The Impact of Prior Authorization on Outpatient
Utilization in Managed Behavioral Health Plans."
[47] D.L. Leslie, R.A. Rosenheck, and S.M. Horwitz, "Patterns of
Mental Health Utilization and Costs Among Children in a Privately
Insured Population," Health Services Research, vol. 36, no.1, Part I
(2001).
[48] R.C. Lindrooth, A.T. Lo Sasso, and I.Z. Lurie, "The Effect of
Expanded Mental Health Benefits on Treatment Initiation and Specialist
Utilization," Health Services Research, vol. 40, no. 4 (2005).
[49] M. Rosenbach et al., Effects of the Vermont Mental Health and
Substance Abuse Parity Law.
[50] K.M. Harris, C. Carpenter, and Y. Bao, "The Effects of State
Parity Laws on the Use of Mental Health Care," Medical Care, vol. 44,
no. 6 (2006).
[51] See D. Dave and S. Mukerjee, "Mental Health Parity Legislation,
Cost-Sharing and Substance-Abuse Treatment Admissions," Health
Economics, vol. 20 (2011); and S.H. Zuvekas, A.E. Rupp, and G.S.
Norquist, "The Impacts of Mental Health Parity and Managed Care in One
Large Employer: a Reexamination," Health Affairs, vol. 24, Iss. 6
(2005).
[52] See K.B. Wells et al., "Alcohol, Drug Abuse and Mental Health
Care for Uninsured and Insured Adults," Health Services Research, vol.
37, no. 4 (2002); and J.E. Wilk et al., "Access to Psychiatrists in
the Public Sector and in Managed Health Plans," Psychiatric Services,
vol. 56, no. 4 (2005).
[53] Wilk et al., "Access to Psychiatrists in the Public Sector and in
Managed Health Plans."
[54] The study sample was limited to 1,203 psychiatrists. While
psychiatrists were less willing to accept patients with certain types
of coverage which affects access, it does not preclude patients from
obtaining services from another provider.
[55] S.H. Busch and C.L. Barry, "New Evidence on the Effects of State
Mental Health Mandates," Inquiry, vol. 45 (2008).
[56] See E.J. Costello, W. Copeland, A. Cowell, and G. Keeler,
"Service Costs of Caring for Adolescents with Mental Illness in a
Rural Community, 1993-2000," The American Journal of Psychiatry, vol.
164 (2007); and K.C. Thomas and L.R. Snowden, "Minority Response to
Health Insurance Coverage for Mental Health Services," The Journal of
Mental Health Policy and Economics, vol. 4 (2001).
[57] J. Klick and S. Markowitz, "Are Mental Health Insurance Mandates
Effective? Evidence From Suicides," Health Economics, vol. 15 (2006).
[58] A.T. Lo Sasso and J.S. Lyons, "The Effects of Copayments on
Substance Abuse Treatment Expenditures and Treatment Reoccurrence,"
Psychiatric Services, vol. 53, no. 12 (2002).
[59] To develop our sampling frame, we used the Dossier function of
the Lexis Nexis corporate database to select 32,431 U.S.-based
companies on January 18, 2011. We selected privately held and publicly
traded parent companies with between 51 to 100,000 employees that were
headquartered in the United States.
[60] Employers had the option of submitting their summary plan
documents--or other documents detailing their coverage, such as a plan
certificate of coverage--for either the current plan year, for the
2008 plan year, or both plan years.
[61] Our stratification was informed by the stratification used by
other published national employer surveys such as Kaiser Family
Foundation and the Health Research and Educational Trust's (Kaiser/
HRET) Employer Health Benefits Annual Survey.
[62] The questions in the survey asking about treatment limitations,
lifetime dollar limits, and cost-sharing amounts were open-ended
responses. Employers could leave these questions blank if their most
popular plans lacked these features.
[63] Kaiser Family Foundation and the Health Research & Educational
Trust, Employer Health Benefits 2010 Annual Survey, September 2010.
[64] Mercer, National Survey of Employer-Sponsored Health Plans: 2010
Survey Report (New York, N.Y.: Mercer, LLC, 2011).
[65] Mercer, National Survey of Employer-Sponsored Health Plans: 2008
Survey Report (New York, N.Y.: Mercer, LLC, 2009).
[66] Our review focused specifically on the effect of health insurance
coverage on enrollee out-of-pocket expenditures.
[67] For the purposes of our literature review, we defined health
insurance as one of the following: having coverage, having limited
availability of coverage, or any absence of health insurance coverage.
We defined health care expenditures as copayments, cost-sharing, and
other out-of-pocket expenditures, and we defined health status as the
quality of care an individual receives or the health outcomes of
receiving care.
[68] We identified published studies included in peer reviewed
journals by conducting a literature search, reviewing literature
suggested to us by experts we interviewed, as well as reviewed
articles referenced in the literature identified during our initial
search.
[End of section]
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