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. Research Question #2: Health Plan and Employer Use of Treatment Limitations

11/01/2013

What types of QTLs (e.g., day limits, visit limits) do group health plans use for MH and SUD conditions, and do such limitations comply with the MHPAEA standards?

2010 Inpatient Quantitative Treatment Limits

Analyses of Milliman's 2010 data suggest that few plans used by large employers were required to make adjustments to their MH/SUD inpatient treatment limitations to be consistent with parity requirements. As shown in Table 15, almost one-fifth of plans (19.3%) covered fewer in-network inpatient days annually for SUD treatment and 16% covered fewer MH inpatient days than medical/surgical inpatient days. About one plan in 20 were required to remove dollar maximums for inpatient MH/SUD treatment.

TABLE 15. QTLs: Percentage of Plans in 2010 Requiring Changes to Inpatient Benefits to be Consistent with MHPAEA  

    Day Limits     Dollar Maximum  
(Annual)
Inpatient in-network MH services 12.5% 4.2%
Inpatient out-of-network MH services 6.8% 4.9%
Inpatient in-network SUD services 19.3% 6.7%
Inpatient out-of-network SUD services 15.5% 6.8%

SOURCE: Milliman's Testing Database of 2010 plan designs.


2010 Outpatient Quantitative Treatment Limits

Outpatient MH/SUD visits were more frequently limited than were inpatient services. Table 16 shows that in 2010 half of the plans covered fewer in-network MH and SUD visits than they covered for medical/surgical outpatient treatment. Nearly two-thirds of the plans needed to modify visit limits for out-of-network outpatient substance use benefits and 14% need to change outpatient out-of-network MH visit limits.

TABLE 16. QTLs: Percentage of Plans in 2010 Requiring Changes to Outpatient Benefits to be Consistent with MHPAEA 

    Visit Limits     Dollar Maximum  
(Annual)
Outpatient in-network MH services 50.0% 0%
Outpatient out-of-network MH services 13.6% 0%
Outpatient in-network SUD services 50.0% 30.0%
Outpatient out-of-network SUD services 63.6% 9.1%

SOURCE: Milliman's Testing Database of 2010 plan designs.


2010 Emergency Care and Prescription Drug Quantitative Treatment Limits

As presented in Table 17, none of the tested plans needed to change their behavioral health emergency care benefits or prescription benefits to comply with MHPAEA and the IFR.

TABLE 17. QTLs: Percentage of Plans in 2010 Requiring Changes to Emergency and Prescription Drug Benefits to be Consistent with MHPAEA  

    Day Limits     Visit Limits     Quality Limits     Dollar Maximums  
(Annual)
Emergency care -- MH/SUD N/A 0% N/A 0%
Prescriptions -- MH/SUD N/A N/A 0% 0%

SOURCE: Milliman's Testing Database of 2010 plan designs.2011 Inpatient Quantitative Treatment Limits


Table 18 present the results of analyses examining consistency with MHPAEA's treatment limitation standards in 2011. By 2011, 100% of Aon Hewitt plans had removed unequal dollar limitations, and there was a significant reduction in the percentage of plans utilizing unequal day limits. These changes suggest substantial movement toward consistency with MHPAEA standards. Still, there was a minority of plans that continued to provide unequal benefits in 2011.

TABLE 18. QTLs: Percentage of Plans in 2011 Requiring Changes to Inpatient Benefits to be Consistent with MHPAEA Standards  

    Day Limits     Dollar Maximum  
Inpatient in-network MH services 7.0% 0%
Inpatient out-of-network MH services 6.5% 0%
Inpatient In-network SUD Services 7.8% 0%
Inpatient out-of-network SUD services 7.0% 0%

SOURCE: Aon Hewitt's Testing Database of 2011 plan designs.2011 Emergency Care and Prescription Drug Quantitative Treatment Limits


As presented in Table 19, none of the plans analyzed needed to change their behavioral health emergency care benefits or prescription benefits to be consistent with MHPAEA and the IFR.

TABLE 19. QTLs: Percentage of Plans Requiring Changes to Emergency and Prescription Drug Benefits to be Consistent with MHPAEA Standards  

    Day Limits     Visit Limits     Quality Limits     Dollar Maximums  
(Annual)
Emergency care -- MH/SUD N/A 0% N/A 0%
Prescriptions -- MH/SUD N/A N/A 0% 0%

SOURCE: Aon Hewitt's Testing Database of 2011 plan designs.


2011 Outpatient Quantitative Treatment Limits

Aon Hewitt's analysis of quantitative outpatient treatment limits in 2011 plans suggests substantial progress from the 2010 Milliman findings. As shown in Table 20, plans apparently made significant strides to improve their quantitative limits in their outpatient MH/SUD benefit designs. None of the plans failed to comply with parity in dollar limitations on outpatient MH/SUD benefits. There were also substantially fewer plans with unequal MH/SUD visit limitations. The percentage of 2011 plans with unequal outpatient SUD benefits ranged between 4% and 6%. These results contrast sharply with results from 2010, when more than 50% of plans tested needed to modify their more restrictive visit limits for outpatient SUD services.

TABLE 20. QTLs: Percentage of Plans Requiring Changes to Outpatient Benefits to Comply with MHPAEA  

    Visit Limits     Dollar Limits  
Outpatient in-network MH services 6.1% 0%
Outpatient out-of-network MH services 4.3% 0%
Outpatient in-network SUD services 6.1% 0%
Outpatient out-of-network SUD services 4.3% 0%

SOURCE: Aon Hewitt's Testing Database of 2011 plan designs.


Changes in Health Plans' Behavioral Health Quantitative Treatment Limits 2009-2011

Inpatient Quantitative Treatment Limits

Aon Hewitt's PDD was used to assess changes in quantitative limits in plan designs between 2009 and 2011.As shown in Table 21 and Table 22, the data suggest that most plans that appeared not to conform to MHPAEA standards in 2009 modified their quantitative limits by 2011 to eliminate more restrictive MH/SUD quantitative limits. For example, in 2009, approximately 50% of the plans covered fewer MH and SUD inpatient in-network days annually than they covered for treatment of medical/surgical conditions. In 2010, that percentage dropped to 12% for MH services and 13.8% for SUD. By 2011, 7.5% of plans covered fewer MH inpatient in-network days and 8.5% covered fewer SUD inpatient days than they covered for medical/surgical conditions. Plans with more restrictive out-of-network inpatient MH day limits declined from more than 48% in 2009 to 10.5% in 2010 and 5.8% in 2011. More limited SUD out-of-network inpatient days were found in 40% of plans in 2009, decreasing to 7.6% in 2011. Similar declines were observed in lifetime MH and SUD inpatient day limitations. Although these declines are notable, one in 12 plans continued to impose annual in-network inpatient MH and SUD day limits that were more restrictive than medical/surgical benefits, and 4% had lifetime MH and SUD day limits that were more restrictive.

TABLE 21. QTLs: MH/SUD Inpatient In-Network Treatment Limitations That Were More Restrictive Than Medical/Surgical Treatment Limitations, 2009-2011  

    2009 Percent of Plans     2010 Percent of Plans     2011 Percent of Plans  
Mental Health
Day limits (annual) 54.0% 12.0% 7.5%
Day limits (lifetime) 13.0% 5.4% 4.0%
Dollar limits (annual) 0.5% 0.2% 0.2%
Dollar limits (lifetime) 0% 0% 0%
Episode limits 1.9% 1.2% 0.8%
Substance Abuse
Day limits (annual) 46.2% 13.8% 8.5%
Day limits (lifetime) 21.4% 5.4% 4.1%
Dollar limits (annual) 0.1% 0.1% 0.0%
Dollar limits (lifetime) 0% 0% 0%
Episode limits 2.5% 1.1% 0.4%

SOURCE: Aon Hewitt's Plan Design Database (2009-2011).


TABLE 22. QTLs: MH/SUD Inpatient Out-of-Network Treatment Limitations That Were More Restrictive Than Medical/Surgical Treatment Limitations, 2009-2011  

    2009 Percent of Plans     2010 Percent of Plans     2011 Percent of Plans  
Mental Health
Day limits (annual) 48.2% 10.5% 5.8%
Day limits (lifetime) 8.1% 1.4% 1.1%
Dollar limits (annual) 0.2% 0.2% 0.2%
Dollar limits (lifetime) 0% 0% 0%
Confinement limits 0.9% 0.3% 0.1%
Substance Abuse
Day limits (annual) 40.4% 12.7% 7.6%
Day limits (lifetime) 8.1% 1.4% 1.1%
Dollar limits (annual) 0.1% 0.1% 0.1%
Dollar limits (lifetime) 0% 0% 0%
Confinement limits 1.7% 1.0% 0.7%

SOURCE: Aon Hewitt's Plan Design Database (2009-2011).


Very few plans applied more restrictive annual and lifetime dollar limits or covered-episode limits on inpatient MH/SUD services than medical/surgical benefits in 2009. There were small declines in 2010 and 2011 in the proportion of plans that had more restrictive dollar or episode limits. The Mental Health Parity Act of 1996 prohibited unequal MH annual and lifetime dollar and covered episodes limits. Our analyses confirm that plans overwhelmingly complied for MH and for SUD, even though the latter conditions were not covered by the 1996 Act.

Outpatient Quantitative Treatment Limitations

As shown in Table 23 and Table 24, more restrictive MH/SUD quantitative outpatient treatment limits decreased sharply between 2009 and 2011. In 2009, more than half of the plans analyzed had more restrictive outpatient in and out-of-network MH and SUD visit and dollar limits than medical/surgical benefits. In 2010, unequal coverage dropped to approximately 11%, and by 2011, the proportion that appeared to offer benefits that were not consistent with MHPAEA standards was about 6%. Very few plan options (less than 1%) had more restrictive annual dollar limits for outpatient MH services than for medical/surgical care. But, consistently, SUD outpatient dollar limits were more likely to be lower than medical/surgical coverage. In 2009, nearly 10% of plans had more restrictive annual dollar limits on outpatient SUD. The percentage of plans with lower annual dollar limits for in-network outpatient SUD decreased to 1.5% in 2010 and to 1.0% in 2011. Similarly, the proportion of plans with lower annual dollar limits for out-of-network SUD outpatient treatment declined from 9.8% in 2009 to 2.9% in 2010 and 1.3% in 2011. The 1996 Mental Health Parity Act did not cover disparities in outpatient SUD dollar or treatment episode limits. Instead, these changes may suggest movement by plans to comply with provisions of the PPACA prohibiting lifetime dollar limits and phasing out annual dollar limits that became effective in 2010.

TABLE 23. QTLs: MH/SUD Outpatient In-Network Treatment Limitations That Were More Restrictive Than Medical/Surgical Treatment Limitations, 2009-2011  

    2009 Percent of Plans     2010 Percent of Plans     2011 Percent of Plans  
Mental Health
Visit limitations 56.1% 11.1% 6.5%
Dollar limitations (annual) 0.8% 0.6% 0.7%
Substance Abuse
Visit limitations 51.1% 12.7% 8.5%
Dollar limitations (annual) 9.4% 1.5% 1.0%

SOURCE: Aon Hewitt's Plan Design Database (2009-2011).



TABLE 24
. QTLs: MH/SUD Outpatient Out-of-Network Treatment Limitations Were More Restrictive Than Medical/Surgical Treatment Limitations, 2009-2011  

    2009 Percent of Plans     2010 Percent of Plans     2011 Percent of Plans  
Mental Health
Visit limitations 59.6% 11.0% 6.4%
Dollar limitations (annual) 0.5% 0.3% 0.2%
Substance Abuse
Visit limitations 53.2% 14.0% 9.0%
Dollar limitations (annual) 9.8% 2.9% 1.3%

SOURCE: Aon Hewitt's Plan Design Database (2009-2011).


Quantitative Limits Among Midsized Employers. Information on day limitations and visit limitations were abstracted from SPDs provided by BLS. As shown in Table 25, in 2008, before MHPAEA implementation, 88% of midsized employers' plans in our limited sample had inpatient day limitations that were more restrictive for MH/SUD conditions than for medical/surgical conditions. Following the implementation of parity, the percentage dropped to 24%. As seen in Appendix D, in each year following parity there were fewer plans utilizing more restrictive day limits for inpatient MH/SUD care than medical/surgical care, so that by 2011, only 13% of plans in our sample still appeared to provide more restrictive MH/SUD day limitations. Likewise, before the implementation of parity, 84% of midsized plans in our sample used outpatient visits limitations that were more restrictive for MH/SUD than medical/surgical benefits. Following the implementation of parity, 26% of these plans provided more restrictive visit limitations for MH/SUD services than medical/surgical services. Again, the percentage of plans providing more restrictive MH/SUD services dropped each year following the implementation of MHPEA, so that by 2011, only 13% of plans in our sample provided outpatient visit limitations that were more restrictive for MH/SUD than medical/surgical services. Caution is warranted so as to not over-interpret the decline, as only a small number of SPDs were available for analysis for each of the post-parity years. Nevertheless, it appears that the pattern of decreasing percentages of plans serving midsized employers that had more restricted MH/SUD quantitative limits is consistent with the pattern observed among large employers' health benefits.

TABLE 25. Treatment Limitations: Percentage of Midsized Employers' Plans in Our Limited Sample That Appear to Include More Restrictive MH/Substance Abuse Treatment Limitations Than Medical/Surgical Limitations

  Pre-Parity
(2008-2009)
Percent of Plans
(n = 167)
Combined Post- Parity Sample
(2010-2011)
Percent of Plans
(n = 73)
Inpatient care: day limits for MH/SUD treatment higher than inpatient medical/surgical care 73% 17%
Outpatient care: visit limits for MH/SUD treatment higher than inpatient medical/surgical care 79% 18%

SOURCE: Author's weighted analysis of data abstracted from SPDs provided by BLS.


Employer Surveys. The nationally representative employer health benefits surveys conducted by KFF/HRET and Mercer in 2010 provide additional perspectives on QTLs following the effective date of MHPAEA. In 2010, the KFF/HRET survey asked whether employers had eliminated limits in MH/SUD as a result of MHPAEA. Table 26 shows that one in five employers reported eliminating limits in coverage in response to MHPAEA. Employers with more than 1,000 workers, firms with self-insured plans, and firms in the transportation and communication industries were most likely to report removing limits on MH/SUD benefits. It cannot be determined from the KFF/HRET data, however, whether firms that did not report changing their benefits already had equitable benefits and did not need to make changes, or if they had inequitable benefits but did not take steps to change. The findings do indicate that a sizeable percentage of employers and health plans are making MHPAEA-related benefit adjustments.

TABLE 26. Percentage of Firms That Changed MH Benefits As a Result of MHPAEA by Firm and Worker Characteristics

    Eliminated Limits In Coverage  
All Firms 20.6%
Firm Size
50-199 employees 15.7%*
200-999 employees 24.1%
More than 1,000 employees 50.3%*
Geography
Northeast 14.6%*
Midwest 27.1%
South 24.6%*
West 14.7%
Plan Funding
Underwritten by insurer 14.2%*
Self-insured 34.7%

SOURCE: Estimates are from author analysis of data from 2010 Henry J. Kaiser Family Foundation/Health Research and Educational Trust 2010 Employer Health Benefits Survey public use file.

* Estimate is statistically different from reference group (P < 0.05). Reference groups were assigned as follows: firm size = 200-999 employees; region = South; plan funding = self-insured.


The 2010 Mercer Health Benefits Survey also asked employers whether they had made changes in benefit designs to meet parity requirements. More than seven in ten employers (74%) responded that no changes were necessary because their benefits already complied with MHPAEA. As shown in Table 27, of the 1,433 employers responding to the 2010 Mercer survey, 17% reported removing limitations in the number of office visits, inpatient days or dollar limits for MH/SUD benefits in response to MHPAEA requirements. Although the 2010 KFF/HRET and Mercer surveys differ somewhat in the proportion of respondents who report making quantitative changes in their MH/SUD benefits in response to MHPAEA, both reflect considerable activity among employers in response to MHPAEA.

TABLE 27. Employer Response to MHPAEA: Results From the 2010 Mercer Survey  

    Sample Size     Remove Limits  
Total 1,433 17%
Firm Size
Fewer than 500 employees 332 15%
More than 500 employees 1,101 35%
Region
Northeast 216 34%
Midwest 334 42%
South 359 32%
West 192 32%

SOURCE: 2010 Mercer Health Benefits Survey.

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