New (Final) Rules in Mental Health Parity: I
Join Dr. Owen Muir as he evaluates the rule making adventures of the Federal Government.
Oh my gosh. I am so excited. This is the first part of my series on the new final rules related to mental health parity. A while back, in the good ‘ole days of 2023, the Department of Labor and HHS issued a proposed rule related to mental health parity. I don’t want to brag, but I wrote four classic hip-hop-themed articles advocating soliciting open comments:
Macklemore + Ryan Lewis: “Thrift Shop”
And one non-hip-hop themed article, including the math I hoped DOL would advocate using:
Mental Health Parity Enforcement Made Simple
Suffice it to say: I was hoping the final rule drop would be hot.
This will be a thrilling breakdown of the updates to important federal rules. I’ll try to keep you awake—I promise.
The Mental Health Parity and Addiction Equity Act proposed that health plans have equivalent coverage standards for mental health and substance use (MH/SUD) care compared to medical/surgical care. However, the definitions of terms like “should,” “have,” “equivalent,” “coverage,” “standards,” “mental health and substance use,” “care,” and “medical/surgical” were all left inexactly defined, so there has been no meaningful enforcement. According to the final rule, the far too wordy purpose of the law is:
to ensure that participants and beneficiaries in a group health plan or in group health insurance coverage offered by a health insurance issuer that offers mental health or substance use disorder benefits are not subject to greater restrictions when seeking those benefits than when seeking medical/surgical benefits under the terms of the plan or coverage
That’s a mouthful! I might have said, “to ensure mental health coverage is not worse than other coverage.” This is why I don’t have a cushy government job, clearly.
The Department of Labor is attempting, along with HHS and other agencies, to change that by tightening standards. It’s a 536-page document. I’m doing my best to understand key points and communicate them to you, starting with:
What Counts as a Mental Health/Substance Use Disorder?
If it is in ICD (the International Classification of Disease System, currently used in the US as ICD-10) or DSM (the Diagnostic and Statistical Manual). In that case, it’s included — including dementia and autism.
As noted in a footnote:
As discussed later in this preamble, the Departments stated in the proposed rules and reiterate in these final rules that ASD is a mental health condition for purposes of MHPAEA. (footnote 50, p. 21)
This is a huge deal, financially, because, according to UC Davis:
Their forecasts for ASD-related medical, nonmedical and productivity losses are $268 billion for 2015 and $461 billion for 2025. The researchers noted that these estimates are conservative and, if ASD prevalence continues to increase as it has in recent years, the costs could reach $1 trillion by 2025.
Further, once the DSM or ICD is updated, whichever is more recent, and a “new” mental health diagnosis exists, that becomes part of what needs to be covered within 60 days of its publication in the federal register:
The proposed definitions stated that the most current version of the ICD or DSM, respectively, would be the version applicable no earlier than the date that is 1 year before the first day of the applicable plan year; however, the proposed rules would permit the use of an updated version before the plan or issuer is required to use it. (p.25)
The reason this relatively simple choice of definition is a huge deal may be non-obvious. Let me help: