February 22, 2019
State and federal law require insurance companies and certain government programs, including Medicaid and CHIP managed care, to ensure equal access to treatment for mental health conditions and substance use disorders as compared to medical and surgical health benefits.
Health-care parity, as the concept is known, recognizes that treatment of mental health conditions and substance use disorders is just as important as physical health.
“Insurance companies can’t create different conditions for getting access to different kinds of care,” said Avril Hunter, HHS ombudsman for behavioral health, which serves as the neutral party in disputes. “For example, they can’t have more difficult prior authorization policies for mental health than physical.”
That includes different co-pays and out-of-pocket limits between mental and physical health. For example, insurance companies can’t charge higher co-pays for a covered mental health benefit or limit the number of visits or covered days in a hospital for substance abuse, unless the comparable limits apply for similar medical and surgical conditions.
While the federal legislation is 10 years old, Texas lawmakers approved a law in the 2017 legislative session to require additional analysis of parity compliance in Texas and put Hunter’s office in charge of receiving complaints. That includes complaints about Medicaid, private companies and even ERS, which administers HHS employees’ health insurance.
“We route the complaints to the proper authority and report the results to a work group of stakeholders established by the legislature, and we note whether we agree or disagree with the agency’s decision,” Hunter said.
If a Medicaid health plan is found in violation, HHSC will request a plan of action to resolve the issue, or, for more serious violations, require a corrective action plan and could potentially assess liquidated damages if that plan isn’t followed. The Texas Department of Insurance will respond in a similar way for CHIP violations.
Hunter said it’s important to note the law doesn’t require insurance companies to provide mental and behavioral coverage. But it can’t add extra burdens to access that care if it does.