The Biden administration yesterday announced new, tougher rules aimed at pushing health insurers to comply with a 15-year-old federal law requiring them to cover mental health services on par with treatment for physical health.

“We must fulfill the promise of mental health parity for all Americans now,” Biden said in his speech. “Now.”

Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008 in an effort to expand patients’ access to mental health care. It built on similar, previous legislation and was based on the principle that insurers should treat mental health conditions and substance use disorders like any other health condition, ending insurance industry practices that seemed to routinely discriminate against people with mental health conditions.

But the reality has been far messier as Americans seeking treatment for mental illness and substance abuse have continued to face an array of obstacles put up by their insurance plans. Therapies may be deemed “not medically necessary,” coverage of inpatient hospital stays often ends well before doctors recommend and proven treatments may be excluded entirely. In some cases, for example, insurers refuse to pay a nutritionist to help a person with an eating disorder, while covering them for a person with diabetes.

Other barriers include requiring treatment to be pre-approved by the insurance company, which can delay care in a crisis, and providing an inadequate number of mental health professionals in an insurance company’s network. A 2019 study found that insured patients are almost six times more likely to go out of their insurer’s network, resulting in higher out-of-pocket costs or no care at all. 

Advocates and patients say insurers have been able to continue discriminatory practices by using the vagueness of the laws and regulations designed to enforce them to fashion their own standards for deciding when to cover or decline authorization for treatment. 

The proposed rule will force health insurers, including Medicaid managed-care plans, to identify gaps in care. This means evaluating the number of mental health providers in an insurer’s network and assessing how often prior authorization occurs, as well as comparing reimbursement rates paid to providers. Reporting the data is required to ensure compliance with the law.

“It’s a very big step,” said David Lloyd, chief policy officer at The Kennedy Forum, a nonprofit mental health group that has been a leading advocate for stronger parity legislation and enforcement. “It’s by far the biggest step in a decade to improving access to mental health and addiction care.”

The proposed rules will put “much-needed teeth into the Federal Parity Act regulations, which are critical to saving lives amidst our nation’s ongoing mental health and substance use crisis,” the Kennedy Forum said in a statement. Lloyd hopes the Biden Administration will finalize strong regulations when the 60-day public comment period on the proposed rules ends.

(Note: Patrick Kennedy, a mental health advocate and former Congressman who founded the Kennedy Forum, is a member of the editorial advisory board of MindSite News.)

The new rules apply to commercial insurers, state-run Medicaid programs and Medicaid managed-care plans run by private insurers, but they don’t touch Medicare, because parity legislation didn’t extend to the federal health insurance program for seniors. (A bill recently introduced in Congress would change that.) 

Biden’s announcement is the latest effort by the administration to expand coverage for mental health treatment and reframe mental illness and substance use as chronic conditions deserving of equal attention. Early last year, the Labor Department announced it was stepping up enforcement of existing parity laws and, in a report to Congress, painted a picture of a recalcitrant insurance industry that is failing to comply with laws that have been on the books for years. 

“I don’t know what the difference between breaking your arm and having a mental breakdown is. It’s health,” Biden said yesterday. “It’s essential to people’s wellbeing and their ability to lead a full and productive life, to find joy, to find purpose, to take care of themselves and their loved ones. It’s about dignity.