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Network adequacy echoes parity laws

March 6, 2017
by Jill Sederstrom
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In some markets, patients with insurance are having a tough time finding available in-network providers for behavioral health services. Network adequacy is an important component to achieving mental health parity, however, significant obstacles make it difficult to accomplish.

Under the Health Parity and Addiction Equity Act of 2008 (MHPAEA), health insurance providers are prohibited from imposing less favorable benefit limitations on mental health and substance use disorders than they impose on medical or surgical benefits.

One aspect of parity, is the concept of network adequacy, or the idea that there are sufficient providers within an area to meet to the needs of the health plan’s beneficiaries. Under the Affordable Care Act, it’s required that health plans participating as qualified health plans in the marketplace meet network adequacy standards.

“Failing to meet network adequacy is one of several ways that a health plan can fall short in meeting parity requirements and effectively discriminate between med/surg care and mental health or addiction treatment,” says Harry Nelson, JD, founder and managing partner of Nelson Hardiman, a Los-Angeles based law firm that focuses on healthcare regulation.

The network adequacy requirements are quantitative, which means that adequacy is determined by factors such as waiting times or geographic distances to a mental health provider.

“If you can’t find a provider, you can’t get care,” says Dania Douglas, JD, manager of policy and state outreach for the National Alliance on Mental Illness.  “And if you can’t find a provider within a three hour drive, you can’t get care. It ends up costing a lot more essentially. You feel your only option is going out of network, or you don’t even have the option of going out of network if you are in an HMO. Then it really is an access to care issue.”

Obstacles to enforcement

But while experts agree that network adequacy is a component of parity, enforcement of parity overall and network adequacy in particular remains a challenge.

“One of the problems with the mental health parity act is that it really hasn’t been enforced,” Douglas says. “It’s very much what we call a complaint-driven system at the moment where a person has to complain about a problem they encounter—and it depends on the type of insurance claim who you have to complain to.”

Hardiman says MHPAEA’s own terms and recent federal appellate court decisions have determined there is no private right to enforce parity. Addiction treatment providers and patients aren’t able to do anything other than complain to government agencies asking for intervention.

However, when departments of insurance are reviewing policies, network adequacy is something that they will review as a nonquantitative limit. According to the National Association of Insurance Commissioners, all states have network adequacy standards, and it is something that is reviewed when the policy is first sent for approval, when they receive complaints or when changes are made to the policy that requires additional review.

Current climate

A report released by NAMI in November 2016, examines the issue of network adequacy and the struggles that beneficiaries face as they try to get access to mental health services. The report is based on a 2015 survey of 3,081 individuals with either private or public health insurance.

The survey found that beneficiaries were more likely to use in-network providers for general or specialty medical care than they were for mental health services. According to the data, while 97% of those surveyed reported using an in-network primary care physician, just 73% reported using an in-network mental health therapist.

In addition, when patients need additional care, they are also more likely to use in-network facilities for medical care. The report stated  that 91% used an in-network general hospital for care, while only 67% of those who used a residential mental health facility reported that it was in-network.

“People on Medicaid had a much easier time finding an in-network provider than people with private insurance,” Douglas says.

She believes the reason finding in-network providers is easier for Medicaid beneficiaries is that Medicaid covers a much wider variety of services and will often use psychiatric nurse practitioners and other team members to fill in gaps in care.

Suki Norris, senior knowledge engineer at The Echo Group, says she believes the issue may be less prevalent in Medicaid is because the system already has a network of community based organizations that provide Medicaid services that states have already put in place. 

Overall, Douglas says, NAMI has found that patients are calling repeatedly to find mental health providers and either provider lists are outdated, the provider isn’t taking new patients or there are long wait times to receive care.

Reasons for the Inadequacy

Just what is causing these problems with access? Experts say there are multiple factors that lead to inadequate networks.

For payers, there are many practical challenges to meeting the standards. For instance, they may have difficulty finding mental health providers who are willing to be a part of their network, particularly in rural areas or in specialized areas that have provider shortages, such as child psychiatry.

“From a patient perspective, there have been expression of concerns that real network adequacy depends on much more than meeting numeric requirements, and that there is a lack of real choice for consumers, particularly around specialized kinds of care,” Nelson says.