Health insurance is so complicated that 41% of Americans have avoided getting medical care because they knew or feared insurance wouldn’t cover the costs. Mental health care can be even harder to access.
Amid a mental health crisis that’s gotten worse since the onset of the COVID-19 pandemic, the Biden administration has proposed a rule aimed at lowering barriers to getting mental health and substance abuse treatment. It would require health insurers to show data demonstrating that they’re providing equal access to medical and mental health care.
Why mental health parity has been a challenge
Health insurance companies have long been reluctant to cover mental health treatment, says Dr. Paul Appelbaum, a professor of psychiatry at Columbia University. There was a perception that psychiatric disorders are more difficult to objectively verify and that treatments were vague and susceptible to abuse.
Those arguments largely lost out, and Congress passed the 2008 Mental Health Parity and Addiction Equity Act to put mental health care on equal footing with medical health care. Among its protections:
If a health insurance plan has deductibles or copays or limits on treatment for mental health benefits, those requirements must be no more restrictive than those for medical or surgical benefits.
If a health insurance plan includes out-of-network benefits for medical or surgical services, it must also provide out-of-network benefits for mental health services.
Insurance companies must disclose standards for medical necessity and reasons for any denial of benefits for mental health benefits upon request.
But a 2023 report to Congress on the law showed that many people still face difficulty getting access, because of a lack of in-network providers, high cost, and other barriers. While the 2008 law banned easy-to-measure ways of limiting coverage, insurance companies have come up with “non-quantitative” restrictions, Appelbaum says.
For example, companies may be more likely to require advanced approval or more extensive documentation for treatments for psychiatric conditions compared to general medical conditions.
“They can be highly effective at restricting access to equivalent care for psychiatric disorders, thus undermining the intent of the legislation,” Appelbaum says.
Insurance isn’t the only problem with accessing mental health care. In many places, there aren’t enough providers, especially for children, Appelbaum says.
But insurance has a role to play in the shortage of providers as well — many providers can make more money if they stop taking insurance and only see patients privately.
“Because of the relatively poor reimbursement, many psychiatrists and psychologists who can opt out of the insurance system and see only that small proportion of the patient population who can pay out of pocket, do that,” Appelbaum says.
How to solve the mental health parity problem
The rule proposed by the Biden administration would help reinforce the provisions of the mental health parity act. It would require health insurance companies to collect data evaluating their mental health provider networks, how much they pay out-of-network providers, how often prior authorization is required, and how often prior authorization requests are denied. It would also require health plans to use the same criteria for setting out-of-network payment rates for mental health providers as they do for medical providers.
“Our plans would require health insurance plans to identify the gaps in the mental health care they provide,” President Joe Biden said in remarks announcing the rule.
The administration is accepting public comment on the proposed rule through Oct. 2.
For any rule regarding mental health parity to work, it needs to be enforced. That’s one reason the mental health parity act hasn’t guaranteed parity thus far.
“It’s going to take resources,” Appelbaum says. “Bodies need to be devoted to this kind of monitoring, and it’s going to take aggressive enforcement, because the insurers have every reason to try to continue to undermine the presumption in favor of parity.”
If you’re struggling to find an affordable mental health care provider in your insurance network, you don’t have to wait for the Biden administration to act. There may be alternatives. Your state, county, or municipality may have a community mental health agency that can provide free or low-cost mental health care. Check with your local department of health.
You may also be able to get low-cost care at a nearby academic medical center, from psychiatrists or psychologists in training.
If those options are unavailable, you can also try to negotiate with your therapist of choice. If they don’t take insurance, they may accept payment on a sliding scale. Be sure to also take advantage of any employee benefits that have to do with mental health. Common benefits include virtual coaching and therapy, as well as treatment for sleep disorders and stress.
