Consistency of Large Employer and Group Health Plan Benefits with Requirements of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Inpatient MH/SUD

11/01/2013

Inpatient Benefit Design

Our analysis reviewed the benefit design in effect in each plan year for inpatient medical/surgical and MH/SUD services. We compared the benefits applied to inpatient medical/surgical with those for MH/SUD services to determine if the benefit in place for MH/SUD services is the same as, more restrictive, or less restrictive than medical/surgical services.

For purposes of this analysis, we evaluated only the copay and/or coinsurance levels applied for each plan option. This analysis did not consider day, dollar, or confinement limitations. The analysis on quantitative limitations is reported separately. Results are reported in three categories:

  • Inpatient benefit is the same for MH/SUD and medical/surgical: This category includes all plan options where the copay and/or coinsurance level for MH/SUD and medical/surgical are the same.

    • Example: Inpatient MH/SUD services are covered at 80% coinsurance after the deductible and inpatient medical/surgical services are covered at 80% coinsurance after the deductible.

       

  • Inpatient benefit is more restrictive for MH/SUD than for medical/surgical: This category includes all plan options where the plan applies a more restrictive benefit for MH/SUD than for medical/surgical.

    • Example #1: Inpatient MH/SUD services are covered at 50% coinsurance after deductible and inpatient medical/surgical services are covered at 80% coinsurance after deductible.
    • Example #2: Inpatient MH/SUD services are subject to a $250 copay, then are covered at 80% coinsurance and medical/surgical services are covered at 80% coinsurance.

       

  • Inpatient benefit is less restrictive for MH/SUD than for medical/surgical: This category includes all plan options where the plan applies a less restrictive benefit for MH/SUD than for medical/surgical services.

    • Example: MH/SUD services are covered at 80% coinsurance and medical/surgical services are subject to a $100 copay, then are covered at 80% coinsurance.

       

Observations

For both in-network and out-of-network inpatient benefit designs in all 3 years of this analysis, the vast majority of plan options apply the same benefit design for both medical/surgical and MH/SUD benefits. The data suggests a slight increase in the percent of plans that aligned the inpatient MH/SUD benefit design with the medical/surgical inpatient benefit design from 2009 to 2010 and a decrease in the percent of plan options that applied a more restrictive benefit design for MH/SUD than for medical/surgical. However, the distribution among plans that apply a more restrictive, less restrictive or the same benefit design as medical/surgical stayed relatively stable in all 3 years.

There are a number of plan options that report having a less restrictive MH benefit for inpatient MH services than for medical/surgical services, for example, 11.75% in 2011. Some examples of less restrictive MH benefit designs are listed below:

  • Example #1: MH/SUD services covered at 80% coinsurance (no deductible); medical/surgical services covered at 80% coinsurance after the deductible.

  • Example #2: MH/SUD services covered at 100% after deductible; medical/surgical services covered at 80% coinsurance after deductible.

  • Example #3: MH/SUD services covered at 90% coinsurance; medical/surgical services covered at 80% coinsurance.

Of note is the percentage of plan options where the MH and SUD benefit designs are more restrictive than the medical/surgical inpatient benefit design. Although we cannot confirm these designs are non-compliant with federal parity requirements, they do raise concern. We have provided some examples of the more restrictive benefit design for inpatient MH and SUD as recorded in the PDD below:

  • Example #1: MH/SUD services covered at 90% coinsurance after hospital copay; medical/surgical services covered at 100% coinsurance after hospital copay.

  • Example #2: MH/SUD services covered at 90% coinsurance; medical/surgical services covered at 100%.

  • Example #3: MH/SUD services covered at 80% coinsurance; medical/surgical services covered at 90% coinsurance.

  In-Network Benefit Design     Percent of Plan Options     Number of Plan Options  
  2009     2010     2011     2009     2010     2011  
Mental Health
Inpatient benefit is the same for MH and medical/surgical 79.6% 82.8% 83.3% 4,329 3,862 3,871
Inpatient benefit is more restrictive for MH than for medical/surgical 6.5% 4.5% 4.9% 353 210 228
Inpatient benefit is less restrictive for MH than for medical/surgical 13.9% 12.7% 11.8% 758 594 546
Total   100.00%     100.00%     100.00%   5,440 4,665 4,645
Substance Use Disorders
Inpatient benefit is the same for SUD and medical/surgical 77.2% 79.4% 82.5% 3,548 3,154 3,249
Inpatient benefit is more restrictive for SUD than for medical/surgical   6.4% 5.3% 4.0% 292 211 159
Inpatient benefit is less restrictive for SUD than for medical/surgical 16.5% 15.3% 13.5% 758 606 532
Total 100.0% 100.0% 100.0% 4,598 3,971 3,940

 

  Out-Network Benefit Design     Percent of Plan Options     Number of Plan Options  
  2009     2010     2011     2009     2010     2011  
Mental Health
Inpatient benefit is the same for MH and medical/surgical 80.5% 77.6% 79.1% 1,376 1,354 1,544
Inpatient benefit is more restrictive for MH than for medical/surgical 9.4% 6.5% 5.6% 160 113 110
Inpatient benefit is less restrictive for MH than for medical/surgical 10.1% 15.9% 15.3% 173 278 298
Total   100.00%     100.00%     100.00%   1,709 1,745 1,952
Substance Use Disorders
Inpatient benefit is the same for SUD and medical/surgical 76.7% 75.0% 79.8% 1,164 1,133 1,359
Inpatient benefit is more restrictive for SUD than for medical/surgical   11.1% 5.8% 3.8% 168 88 64
Inpatient benefit is less restrictive for SUD than for medical/surgical 12.3% 19.2% 16.4% 186 290 280
Total 100.00% 100.00% 100.00% 1,518 1,511 1,703

Inpatient Quantitative Limitations

As MHPAEA legislation prohibits group health plans providing coverage for medical/surgical and MH/SUD benefits from imposing more restrictive financial requirements or treatment limitations for MH/SUD than those provided for medical/surgical benefits, our analysis included a review of the plan options that applied quantitative limits, including day, dollar, or confinement limitations, to inpatient MH/SUD services.

The limitations included in this analysis are described below:

  • Inpatient day limitations are typically plan provisions that limit the number of inpatient days covered under the plan and can be annual or lifetime limits.

    • Example: Inpatient MH/SUD services covered up to 20 days per year.

       

  • Inpatient dollar limitations are plan provisions that limit the amount the plan will pay for inpatient MH/SUD services and is typically an annual or lifetime limit.

    • Example: Inpatient MH/SUD services covered up to $10,000 per year and/or $20,000 lifetime.

       

  • Inpatient confinement limitations reflect plan provisions that establish limits regarding each MH/SUD confinement.

    • Example: Inpatient MH/SUD services are limited to one confinement per lifetime.

       

Observations

The data suggests that most plan options reflected in the PDD have made modifications from 2009 to 2011 to eliminate quantitative limitations on inpatient MH/SUD benefits and are offering the MH/SUD benefits in parity with medical/surgical.

The plan design data shows a drastic reduction in the percent of plan options that applied annual or lifetime day limits to inpatient MH/SUD benefits. For example, in 2009, approximately half of the plan options reported applying annual day limits on in-network inpatient MH and SUD benefits. In 2010, the percent of plan designs that apply annual day limits for in-network inpatient MH services decreased to 12.01% for MH and 13.84% for SUD. A similar trend was observed in out-of-network benefit designs. No significant change was noted in limits in 2011.

Few plan options reported applying annual and lifetime dollar and confinement limitations on inpatient MH/SUD services in 2009. These statistics stayed relatively stable in 2010 and 2011 with no significant change in the percent of plans with dollar or confinement limitations. Although the majority of plan options do not apply these types of quantitative limits to inpatient MH/SUD services, the data does show some options with quantitative limits that are more restrictive for MH/SUD than for medical/surgical.

Quantitative limitations on MH/SUD benefits that are more restrictive than medical/surgical could potentially be non-compliant with MHPAEA requirements. However, we were not able to assess the compliance status of those plans that report such limits on inpatient MH/SUD services.

  In-Network Limitations     Percent of Plan Options     Number of Plan Options  
  2009     2010     2011     2009     2010     2011  
Mental Health
Day limitations (annual)
   Day limits are more restrictive for MH than medical/surgical 54.0% 12.0% 7.5% 3,337 635 393
   Day limits are less restrictive for MH than for medical/surgical 0.1% 0.1% 0.1% 8 7 5
   Day limits are the same for MH and medical/surgical (no limits in place) 45.9% 87.9% 92.4% 2,839 4,647 4,814
Total 100.0% 100.0% 100.0% 6,184 5,289 5,213
Day limitations (lifetime)
   Day limits are more restrictive for MH than medical/surgical 13.0% 5.4% 4.0% 803 283 210
   Day limits are less restrictive for MH than for medical/surgical 0.0% 0.0% 0.0% 1 2 1
   Day limits are the same for MH and medical/surgical (no limits in place) 87.0% 94.6% 96.0% 5,380 5,004 5,002
Total 100.0% 100.0% 100.0% 6,184 5,289 5,213
Dollar limitations (annual)
   Dollar limits are more restrictive for MH than medical/surgical 0.5% 0.2% 0.2% 29 9 10
   Dollar limits are less restrictive for MH than for medical/surgical 0.0% 0.0% 0.0% 1 1 0
   Dollar limits are the same for MH and medical/surgical (no limits in place) 99.5% 99.8% 99.8% 6,154 5,279 5,203
Total 100.0% 100.0% 100.0% 6,184 5,289 5,213
Dollar limitations (lifetime)
   Dollar limits are more restrictive for MH than medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Dollar limits are less restrictive for MH than for medical/surgical 0.3% 0.1% 0.1% 16 6 5
   Dollar limits are the same for MH or medical/surgical (no limits in place) 99.5% 99.6% 99.7% 6,155 5,270 5,195
Total 100.0% 100.0% 100.0% 6,171 5,276 5,200
Confinement limitations
   Confinement limits are more restrictive for MH than medical/surgical 1.9% 1.2% 0.8% 116 64 43
   Confinement limits are less restrictive for MH than for medical/surgical 0.3% 0.3% 0.3% 21 17 17
   Confinement limits are the same for MH or medical/surgical (no limits in place) 97.8% 98.5% 98.8% 6,045 5,208 5,151
Total 100.0% 100.0% 100.0% 6,184 5,289 5,213
Substance Use Disorders
Day limitations (annual)
   Day limits are more restrictive for SUD than medical/surgical 46.2% 13.8% 8.5% 2,562 656 395
   Day limits are less restrictive for SUD than for medical/surgical 0.2% 0.7% 0.2% 12 32 10
   Day limits are the same for SUD and medical/surgical (no limits in place) 53.6% 85.5% 91.3% 2,975 4,053 4,236
Total 100.0% 100.0% 100.0% 5,549 4,741 4,641
Day limitations (lifetime)
   Day limits are more restrictive for SUD than medical/surgical 21.4% 5.4% 4.1% 1,187 285 212
   Day limits are less restrictive for SUD than for medical/surgical 0.1% 0.1% 0.1% 3 5 5
   Day limits are the same for SUD and medical/surgical (no limits in place) 78.5% 94.5% 95.8% 4,356 4,999 4,996
Total 100.0% 100.0% 100.0% 5,546 5,289 5,213
Dollar limitations (annual)
   Dollar limits are more restrictive for SUD than medical/surgical 0.1% 0.1% 0.0% 3 3 2
   Dollar limits are less restrictive for SUD than for medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Dollar limits are the same for SUD and medical/surgical (no limits in place) 99.9% 99.9% 99.9% 5,539 4,727 4,628
Total 100.0% 100.0% 100.0% 5,542 4,730 4,630
Dollar limitations (lifetime)
   Dollar limits are more restrictive for SUD than medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Dollar limits are less restrictive for SUD than for medical/surgical 5.3% 0.8% 0.7% 293 37 31
   Dollar limits are the same for SUD and medical/surgical (no limits in place) 94.7% 99.2% 99.3% 5,258 4,704 4,608
Total 100.0% 100.0% 100.0% 5,551 4,741 4,639
Confinement limitations
   Confinement limits are more restrictive for SUD than medical/surgical 2.5% 1.1% 0.4% 141 50 19
   Confinement limits are less restrictive for SUD than for medical/surgical 1.2% 1.0% 0.9% 64 47 42
   Confinement limits are the same for SUD or medical/surgical (no limits in place)   96.3% 98.0% 99.0% 5,346 4,645 4,580
Total 100.0% 100.0% 100.0% 5,551 4,742 4,641

 

  Out-Network Limitations     Percent of Plan Options     Number of Plan Options  
  2009     2010     2011     2009     2010     2011  
Mental Health
Day limitations (annual)
   Day limits are more restrictive for MH than medical/surgical 48.2% 10.5% 5.8% 1,252 249 146
   Day limits are less restrictive for MH than for medical/surgical 0.5% 0.5% 0.2% 14 11 4
   Day limits are the same for MH or medical/surgical (no limits in place) 51.3% 89.0% 94.1% 1,331 2,110 2,388
Total 100.0% 100.0% 100.0% 2,597 2,370 2,538
Day limitations (lifetime)
   Day limits are more restrictive for MH than medical/surgical 8.1% 1.4% 1.1% 210 33 28
   Day limits are less restrictive for MH than for medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Day limits are the same for MH and medical/surgical (no limits in place) 91.9% 98.6% 98.9% 2,387 2,337 2,510
Total 100.0% 100.0% 100.0% 2,597 2,370 2,538
Dollar limitations (annual)
   Dollar limits are more restrictive for MH than medical/surgical 0.2% 0.2% 0.2% 4 4 5
   Dollar limits are less restrictive for MH than for medical/surgical 0.0% 0.0% 0.1% 1 0 3
   Dollar limits are the same for MH or medical/surgical (no limits in place) 99.8% 99.8% 99.7% 2,592 2,366 2,530
Total 100.0% 100.0% 100.0% 2,597 2,370 2,538
Dollar limitations (lifetime)
   Dollar limits are more restrictive for MH than medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Dollar limits are less restrictive for MH than for medical/surgical 0.1% 0.0% 0.0% 3 0 1
   Dollar limits are the same for MH or medical/surgical (no limits in place) 99.6% 99.7% 99.7% 2,587 2,363 2,530
Total 100.0% 100.0% 100.0% 2,590 2,363 2,531
Confinement limitations
   Confinement limits are more restrictive for MH than medical/surgical 0.9% 0.3% 0.1% 24 7 3
   Confinement limits are less restrictive for MH than for medical/surgical 0.0% 0.0% 0.4% 0 0 11
   Confinement limits are the same for MH or medical/surgical (no limits in place) 99.1% 99.7% 99.9% 2,573 2,363 2,535
Total 100.0% 100.0% 100.0% 2,597 2,370 2,538
Substance Use Disorders
Day limitations (annual)
   Day limits are more restrictive for SUD than medical/surgical 40.4% 12.7% 7.6% 924 266 174
   Day limits are less restrictive for SUD than for medical/surgical 0.5% 0.6% 0.3% 12 12 6
   Day limits are the same for SUD or medical/surgical (no limits in place) 59.0% 86.8% 92.1% 1,349 1,824 2,099
Total 100.0% 100.0% 100.0% 2,285 2,102 2,279
Day limitations (lifetime)
   Day limits are more restrictive for SUD than medical/surgical 8.1% 1.4% 1.1% 210 33 28
   Day limits are less restrictive for SUD than for medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Day limits are the same for SUD or medical/surgical (no limits in place) 91.9% 98.6% 98.9% 2,387 2,337 2,510
Total 100.0% 100.0% 100.0% 2,597 2,370 2,538
Dollar limitations (annual)
   Dollar limits are more restrictive for SUD than medical/surgical 0.1% 0.1% 0.1% 3 3 2
   Dollar limits are less restrictive for SUD than for medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Dollar limits are the same for SUD or medical/surgical (no limits in place) 99.9% 99.9% 99.9% 2,275 2,092 2,270
Total 100.0% 100.0% 100.0% 2,278 2,095 2,272
Dollar limitations (lifetime)
   Dollar limits are more restrictive for SUD than medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Dollar limits are less restrictive for SUD than for medical/surgical 7.3% 1.1% 0.8% 166 22 18
   Dollar limits are the same for SUD and medical/surgical (no limits in place) 92.7% 99.0% 99.2% 2,119 2,080 2,261
Total 100.0% 100.0% 100.0% 2,285 2,102 2,279
Confinement limitations
   Confinement limits are more restrictive for SUD than medical/surgical 1.7% 1.1% 0.7% 39 22 16
   Confinement limits are less restrictive for SUD than for medical/surgical 0.0% 0.0% 0.0% 0 0 0
   Confinement limits are the same for SUD and medical/surgical (no limits in place)   98.3% 99.0% 99.3% 2,246 2,080 2,263
Total 100.0% 100.0% 100.0% 2,285 2,102 2,279
 

 

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