“Accessing Specialty Behavioral Health Treatment in Private Health Plans.” By Elizabeth L. Merrick, Constance M. Horgan, Deborah W. Garnick, Sharon Reif, and Maureen T. Stewart; published 2009 in The Journal of Behavioral Health Services & Research.

• ABSTRACT: Connecting people to mental health and substance abuse services is critical, given the extent of unmet need. The way health plans structure access to care can play a role. This study examined treatment entry procedures for specialty behavioral health care in private health plans, and their relationship with behavioral health contracting arrangements, focusing primarily on initial entry into outpatient treatment. The data source was a nationally representative health plan survey on behavioral health services in 2003 (N= 368 plans with 767 managed care products; 83% response rate). Most health plan products initially authorized six or more outpatient visits if authorization was required, did not routinely conduct telephonic clinical assessment, had standards for timely access, and monitored wait time. Products with carve-outs differed on several treatment entry dimensions. Findings suggest that health plans focus on timely access and typically do not heavily manage initial entry into outpatient treatment.

The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd edition. Edited by David Mee-Lee; published 2013 by the American Society of Addiction Medicine.

• OVERVIEW: The ASAM Criteria textbook is the primary source for treatment providers who are applying the criteria in a clinical setting. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions addresses a wide range of special populations and includes the latest addiction science.

“Cost Sharing and Mental Health Care: A Cautionary Tale From the Netherlands.” By Benjamin G. Druss; published 2017 in JAMA Psychiatry.

• ABSTRACT: Since health insurance first began covering mental health services in the mid-20th century, there have been debates about how best to balance comprehensiveness and affordability of mental health care benefits. In the United States, concerns about potential overuse initially led insurers to impose higher restrictions for mental health care than for other types of health care benefits. Over time, advocacy coupled with research demonstrating that these restrictions could be lifted without significant cost increases helped pave the way for broader mental health care coverage. During the past decade, federal legislation has placed mental health within the mainstream of health insurance, establishing it as an essential health benefit and ensuring that it covers a range of services comparable to those for other types of medical and surgical care.

“In name only? Mental health parity or illusory reform.” By Meiram Bendat; published 2014 in Psychodynamic Psychiatry.

• ABSTRACT: The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act mandate significant insurance and patient protection reforms. Despite these safeguards, lax regulatory enforcement and lack of consumer and provider sophistication have failed to remedy ongoing insurer abuses resulting in deprivation of crucial mental health and substance abuse treatment. Even with persistent and informed advocacy, including strategies outlined herein, any potential parity gains are negated by unreasonably low reimbursement benchmarks already used by insurers in many ACA (∗) -exchange plans. The need for legislative remediation is therefore urgent.

“Medical Necessity in Private Health Plans: Implications for Behavioral Health Care.” By Sara Rosenbaum, Brian Kamoie, D. Richard Mauery, Brian Walitt; published 2003 by the Department of Health and Human Services.

• SUMMARY: This report addresses how the term “medical necessity” is defined in private health insurance coverage decisions. It summarizes a review of the literature, an extensive review of legal cases that challenge insurer decisions, materials prepared by the insurance industry, consultation with experts in the field, a review of investigations conducted by State departments of insurance and attorneys general, and interviews with health care executives regarding the decisionmaking process itself. The report does not explore factors that can affect access to care that might be considered clinically necessary by treating professionals or the effects of medical necessity decisions on therapeutic outcomes.

“Mental Health Parity: The Patient Protection and Affordable Care Act and the Parity Definition Implications.” By Suann Kessler; published 2014 in Hastings Science and Technology Law Journal.

• ABSTRACT: At least twenty-eight percent of American adults suffer from a mental or addictive disorder. However, even today, health insurance coverage for mental health services differs drastically from that of other medical services. Nonetheless, although it has yet to achieve parity with other medical services, health insurance coverage for mental health services has improved over time. Because the recent enactment of the Patient Protection and Affordable Care Act (“PPACA”) appears to have filled the parity gaps left by the Mental Health Parity and Addiction Equity Act of 2008, many claim that mental health parity has finally been achieved. While the PPACA may superficially appear to have plugged all the gaps, the ultimate questions are whether it provides actual mental health parity, and whether it facilitates access to mental health services for those who truly need them. This note takes deeper look into these questions, and reveals that the PPACA may fall short of providing actual parity between mental health and other medical services.

“Psychoanalysis, Dynamic Psychotherapy and Mental Health Parity: The Need for Advocacy.” By Susan G. Lazar; published 2016 in The American Psychoanalyst.

• OVERVIEW: Psychotherapy, especially psychoanalysis and dynamic psychotherapy, has historically been poorly supported by insurance benefits. While there are a number of notable exceptions to this generalization (e.g., CHAMPUS, Medicare, Federal Employee Health Benefits Program in past decades), higher co-pays and lower yearly and lifetime limits for mental health care have been widespread discriminatory limitations. After years of advocacy for increasingly comprehensive mental health parity legislation, the Mental Health Parity and Addiction Equity Act (MHPAEA) enacted on Oct. 3, 2008, is the most sweeping national legal mandate to date for parity for mental health care benefits. The Affordable Care and Patient Protection Act of 2010 (ACA) also strengthened mental health parity and its official description explicitly lists psychotherapy as an “Essential Health Benefit.”