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. Outpatient MH/SUD

11/01/2013

Outpatient Benefit Design

Our analysis reviewed the benefit design in effect in each plan year for outpatient medical/surgical and MH/SUD services. Specifically, our review focused on routine outpatient MH/SUD services compared to the benefit design for medical/surgical office visits for PCP and SCP services.

We recognize that there may be other outpatient services that may fall into the outpatient office visit classification. However, our review is focused on comparing routine outpatient MH/SUD services to medical/surgical office visits, as we felt this comparison to be most relevant to the assessment of how MHPAEA has impacted employer plan designs since implementation. Office visit services for medical/surgical services are the closest in terms of scope to typical outpatient MH/SUD visits, and PCP and SCP office visit benefits are often the point of comparison when determining how outpatient MH/SUD benefits are handled relative to medical/surgical.

Historically, many employers have considered MH/SUD professionals to be specialists and therefore applied a coinsurance or copay that was in alignment with the benefit for SCPs. With MHPAEA, there is recognition that the parity compliant benefit for outpatient MH/SUD services should be determined based on an evaluation of substantially all and predominant. As such, aligning the MH/SUD outpatient benefit to the SCP benefit may or may not be compliant, depending upon the outcome of compliance testing. As we do not have access to employer compliance testing results for the employers represented in the PDD, our analysis focuses on the benefits that are documented on the PDD and the comparison between benefits for routine MH/SUD outpatient services and PCP and SCP office visit services. We are unable to assess the compliance status of the plan options included in this analysis.

The results of our analysis show how outpatient MH/SUD benefits compare to the benefits for PCP and SCP office visit services. This comparison did not consider visit or dollar limits, as these plan provisions were evaluated separately.

Some plan options apply the same level of copay or coinsurance to both PCPs and SCPs. Other plan options apply differing copays or coinsurance for PCPs and SCPs, where the PCP copay or coinsurance is often lower than the SCP copay or coinsurance (referred to as Split Copay/Coinsurance Plans). So that the analysis is clear and results are not skewed, we are reporting the results for each group of plan designs separately.

Comparative results are reported as described below:

Plan Options with Same Copay/Coinsurance for PCPs/SCPs

  • Outpatient MH/SUD benefit is the same as PCP/SCP: This category includes all plan options where the MH/SUD benefit and the benefit for PCPs and SCPs are the same.

    • Example #1: MH/SUD benefit is 80% after deductible; PCP and SCP benefit is 80% after deductible.
    • Example #2: MH/SUD benefit is $30 copay; PCP and SCP benefit is $30 copay.

       

  • Outpatient MH/SUD benefit is more restrictive than PCP/SCP.

    • Example #1: MH/SUD benefit is 50% after deductible; PCP and SCP benefit is 80% after deductible.
    • Example #2: MH/SUD benefit is $50 copay; PCP and SCP benefit is $30 copay.

       

  • Outpatient MH/SUD benefit is less restrictive than PCP/SCP.

    • Example #1: MH/SUD benefit is 90% after deductible; PCP and SCP benefit is 80% after deductible.
    • Example #2: MH/SUD benefit is $20 copay; PCP and SCP benefit is $30 copay.

       

Plan Options with Split Copay/Coinsurance for PCPs/SCPs (copay/coinsurance varies for PCPs and SCPs)

  • Outpatient MH/SUD benefit is the same as PCP: This category includes all plan options where the outpatient MH/SUD benefit and the PCP benefit are the same.

    • Example #1: MH/SUD copay is $20; PCP copay is $20.
    • Example #2: MH/SUD coinsurance is 80%; PCP coinsurance is 80%.

       

  • Outpatient MH/SUD benefit is the same as SCP: This category includes all plan options where the outpatient MH/SUD benefit and the SCP benefit are the same.

    • Example #1: MH/SUD copay is $40; SCP copay is $40.
    • Example #2: MH/SUD coinsurance is 70%; SCP coinsurance is 70%.

       

  • Outpatient MH/SUD benefit is less restrictive than PCP: This category includes all plan options where the MH/SUD benefit is less restrictive than the PCP benefit.

    • Example #1: MH/SUD copay is $10; PCP copay is $20.
    • Example #2: MH/SUD coinsurance is 90%; PCP coinsurance is 80%.

       

  • Outpatient MH/SUD benefit is more restrictive than SCP: This category includes all plan options where the MH/SUD benefit is more restrictive than the SCP benefit.

    • Example #1: MH/SUD copay is $50; SCP copay is $40.
    • Example #2: MH/SUD coinsurance is 60%; SCP coinsurance is 70%.

       

  • Outpatient MH/SUD benefit is more restrictive than PCP but less restrictive than SCP: This category includes all plan options where the MH/SUD benefit falls between the PCP and SCP benefit level.

    • Example #1: MH/SUD copay is $25; PCP copay is $20; SCP copay is $30.
    • Example #2: MH/SUD coinsurance is 75%; PCP coinsurance is 80%; SCP coinsurance is 70%.

       

Observations

Plan Options with Same Copay/Coinsurance for PCPs/SCPs

The vast majority of plan options in each plan year utilized the same copay/coinsurance for in-network outpatient MH as the PCP/SCP benefit. However, the data shows a decrease in the percent of plan options with a MH benefit design that is more restrictive than the PCP/SCP benefit level. For example, in 2009, 12.87% of plan options applied a more restrictive in-network benefit for MH than for PCP/SCP services. This percentage decreased to 1.99% in 2011. A similar trend was observed for outpatient SUD and out-of-network MH and SUD benefits.

Plan Options with Split Copay/Coinsurance for PCPs/SCPs

In 2009, approximately one-third of plan options aligned the outpatient MH benefit with PCP, one-third with SCP, and one-third more or less restrictive than PCP or SCP. In 2010, a distinct change occurred in the benefit for MH services. Almost two-thirds of plan options aligned the MH outpatient benefit with the SCP copay level. In 2011, plan designs changed once again. Over half of plan options reported that the outpatient MH benefit aligned with the PCP benefit.

The changes observed across plan options suggest that employers responded to the parity legislation. In 2010, after the enactment of MHPAEA, many employers aligned the outpatient MH benefit with the SCP level, suggesting that employers made the interpretation that treating a MH provider as a specialist would be compliant under the legislation. The interim final regulations were released in early 2010 (implemented in 2011 for most plans) and clarified that design compliance is governed by a review of the benefit design that represents substantially all and predominant. Plan design information reported for 2011 suggests employers evaluated plan designs once again and made adjustments to comply with the interim final regulations. As a result, more plan options were adjusted to align the outpatient MH benefit design with the PCP benefit level.

The plan design data shows that over half of the plan options aligned the outpatient SUD benefit with the PCP benefit level in all 3 years (2009, 2010, and 2011). In 2009 and 2010, approximately 27% of plan options applied a benefit for outpatient SUD services that was either more restrictive than the SCP benefit level or in between the PCP and SCP benefit level. This changed in 2011 when we observed movement away from this approach and more plan options aligned the outpatient SUD benefit with the SCP benefit level.

  In-Network Benefit Design     Percent of Plan Options     Number of Plan Options  
  2009     2010     2011     2009     2010     2011  
Mental Health
Plan Options With Same Copay/Coinsurance for PCPs/SCPs
   Outpatient MH benefit is the same as PCP/SCP 84.9% 89.8% 93.9% 2,059 2,451 2,357
   Outpatient MH benefit is more restrictive than PCP/SCP 12.9% 5.3% 2.0% 312 144 50
   Outpatient MH benefit is less restrictive than PCP/SCP 2.2% 5.0% 4.0% 54 135 102
Total 100.0% 100.0% 100.0% 2,425 2,730 2,509
Plan Options with Split Copay/Coinsurance for PCPs/SCPs
   Outpatient MH benefit is the same as PCP 33.7% 25.8% 55.8% 778 424 1,093
   Outpatient MH benefit is the same as SCP 32.0% 61.2% 25.2% 739 1,005 494
   Outpatient MH benefit is less restrictive than PCP 6.2% 4.3% 14.1% 144 71 277
   Outpatient MH benefit is more restrictive than SCP 20.4% 3.5% 3.7% 472 58 73
   Outpatient MH benefit is more restrictive than PCP but less restrictive than SCP 7.7% 5.1% 1.2% 179 83 23
Total 100.0% 100.0% 100.0% 2,312 1,641 1,960
Substance Use Disorder
Plan Options With Same Copay/Coinsurance for PCPs/SCPs
   Outpatient SUD benefit is the same as PCP/SCP 73.8% 76.1% 97.6% 535 325 2,007
   Outpatient SUD benefit is more restrictive than PCP/SCP 24.3% 20.8% 1.3% 176 89 26
   Outpatient SUD benefit is less restrictive than PCP/SCP 1.9% 3.0% 1.2% 14 13 24
Total 100.0% 100.0% 100.0% 725 427 2,057
Plan Options with Split Copay/Coinsurance for PCPs/SCPs
   Outpatient SUD benefit is the same as PCP 54.8% 55.0% 52.6% 897 631 657
   Outpatient SUD benefit is the same as SCP 15.1% 13.3% 39.7% 248 152 496
   Outpatient SUD benefit is less restrictive than PCP 2.9% 3.9% 3.1% 48 45 39
   Outpatient SUD benefit is more restrictive than SCP 16.8% 17.4% 2.6% 275 200 32
   Outpatient SUD benefit is more restrictive than PCP but less restrictive than SCP   10.4% 10.4% 1.9% 170 119 24
Total 100.0% 100.0% 100.0% 1,638 1,147 1,248
Mental Health
Plan Options With Same Copay/Coinsurance for PCPs/SCPs
   Outpatient MH benefit is the same as PCP/SCP 72.0% 88.2% 89.3% 1,304 1,518 1,713
   Outpatient MH benefit is more restrictive than PCP/SCP 24.5% 7.5% 8.3% 444 129 160
   Outpatient MH benefit is less restrictive than PCP/SCP 3.4% 4.4% 2.4% 62 75 46
Total 100.0% 100.0% 100.0% 1,810 1,722 1,919
Plan Options with Split Copay/Coinsurance for PCPs/SCPs
   Outpatient MH benefit is the same as PCP 20.7% 48.8% 37.5% 17 20 18
   Outpatient MH benefit is the same as SCP 70.7% 39.0% 27.1% 58 16 13
   Outpatient MH benefit is less restrictive than PCP 2.4% 2.4% 33.3% 2 1 16
   Outpatient MH benefit is more restrictive than SCP 4.9% 7.3% 2.1% 4 3 1
   Outpatient MH benefit is more restrictive than PCP but less restrictive than SCP 1.2% 2.4% 0.0% 1 1 0
Total 100.0% 100.0% 100.0% 82 41 48
Substance Use Disorder
Plan Options With Same Copay/Coinsurance for PCPs/SCPs
   Outpatient SUD benefit is the same as PCP/SCP 74.2% 89.1% 89.4% 1,161 1,332 1,527
   Outpatient SUD benefit is more restrictive than PCP/SCP 22.3% 6.8% 7.4% 349 101 126
   Outpatient SUD benefit is less restrictive than PCP/SCP 3.5% 4.2% 3.2% 55 62 55
Total 100.0% 100.0% 100.0% 1,565 1,495 1,708
Plan Options with Split Copay/Coinsurance for PCPs/SCPs
   Outpatient SUD benefit is the same as PCP Data set too small to report credible results
   Outpatient SUD benefit is the same as SCP
   Outpatient SUD benefit is less restrictive than PCP
   Outpatient SUD benefit is more restrictive than SCP
   Outpatient SUD benefit is more restrictive than PCP but less restrictive than SCP

Outpatient 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 some type of visit or dollar limitation to outpatient MH/SUD services.

The limitations included in this analysis are described below:

  • Outpatient visit limitations are typically plan provisions that limit the number of outpatient visits covered under the plan and can be annual or lifetime limits.

    • Example #1: Outpatient MH/SUD services covered up to 30 visits per year.
    • Example #2: Outpatient MH/SUD services covered up to 100 visits lifetime.

       

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

    • Example: Outpatient MH/SUD services covered up to $5,000 per year and/or $10,000 lifetime.

       

Observations

Similar to the results reflected for inpatient MH/SUD benefits, outpatient data shows a decrease in the percent of plan options with visit and dollar limits for outpatient MH/SUD benefits from 2009 to 2011 and the majority of plan options are offering the MH/SUD benefit in parity with medical/surgical.

The plan design data reported shows a drastic reduction in the percent of plan options that apply visit limitations to outpatient MH and SUD services. In 2009, more than half of the plan options reported applying visit limitations on in-network and out-of-network MH and SUD benefits. In 2010, the percent of plan options that apply visit limitations for in-network and out-of-network MH and SUD benefits decreased to approximately 11% and was further reduced to approximately 6% in 2011.

Few plan options (less than 0.1%) reported applying annual dollar limitations on outpatient MH services, while almost 10% of plan options applied annual dollar limitations to outpatient SUD services in 2009. The percentage of plan options with annual dollar limitations on outpatient MH services remained relatively stable, while the percent of plan options with annual dollar limitations on outpatient SUD services decreased from 2009 to 2010. No significant changes were noted in 2011.

Although the majority of plan options do not apply visit or dollar limitations to outpatient MH and SUD services, in 2011, several plan options continue to report that these limits are in place. Examples of the types of limits in place in 2011 are noted below:

  • Outpatient MH/SUD services covered up to 20 visits per year.
  • Outpatient MH/SUD services covered up to 60 visits lifetime.
  • Outpatient MH/SUD services covered up to $2,000 per year and/or $5,000 lifetime.

     

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 quantitative limits on outpatient MH/SUD services.

  In-Network Limitations     Percent of Plan Options     Number of Plan Options  
  2009     2010     2011     2009     2010     2011  
Mental Health
Visit Limitations
   Visit limitations apply to MH services 56.1% 11.1% 6.5% 3,649 617 359
   No MH visit limitations 43.9% 88.9% 93.5% 2,854 4,939 5,173
Total 100.0% 100.0% 100.0% 6,503 5,556 5,532
Dollar Limitations (Annual)
   Dollar limitations apply to MH services (annual) 0.8% 0.6% 0.7% 52 32 38
   No MH dollar limitations 99.2% 99.4% 99.3% 6,451 5,524 5,494
Total 100.0% 100.0% 100.0% 6,503 5,556 5,532
Substance Use Disorders
Visit limitations apply to SUD services
   Visit limitations apply to SUD services 51.1% 12.7% 8.5% 3,038 639 417
   No SUD visit limitations 48.9% 87.3% 91.5% 2,907 4,378 4,482
Total 100.0% 100.0% 100.0% 5,945 5,017 4,899
Dollar limitations (Annual)
   Dollar limitations apply to SUD services (annual)   9.4% 1.5% 1.0% 561 73 51
   No SUD dollar limitations 90.6% 98.5% 99.0% 5,384 4,944 4,848
Total 100.0% 100.0% 100.0% 5,945 5,017 4,899

 

  Out-Network Limitations     Percent of Plan Options     Number of Plan Options  
  2009     2010     2011     2009     2010     2011  
Mental Health
Visit Limitations
   Visit limitations apply to MH services 59.6% 11.0% 6.4% 1,672 281 171
   No MH visit limitations 40.4% 89.0% 93.6% 1,135 2,279 2,512
Total 100.0% 100.0% 100.0% 2,807 2,560 2,683
Dollar Limitations (Annual)
   Dollar limitations apply to MH services (annual) 0.5% 0.3% 0.2% 14 7 6
   No MH dollar limitations 99.5% 99.7% 99.8% 2,793 2,553 2,677
Total 100.0% 100.0% 100.0% 2,807 2,560 2,683
Substance Use Disorders
Visit limitations apply to SUD services
   Visit limitations apply to SUD services 53.2% 14.0% 9.0% 1,339 320 216
   No SUD visit limitations 46.8% 86.0% 91.0% 1,178 1,959 2,179
Total 100.0% 100.0% 100.0% 2,517 2,279 2,395
Dollar limitations (Annual)
   Dollar limitations apply to SUD services (annual)   9.8% 2.9% 1.3% 246 65 31
   No SUD dollar limitations 90.2% 97.2% 98.7% 2,271 2,214 2,364
Total 100.0% 100.0% 100.0% 2,517 2,279 2,395
 

 

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