The Mental Health Parity and Addiction Equity Act of 2008 is scheduled to go into effect January 1, 2010, and supporters have shifted their focus from applauding its passage to ensuring that federal agencies implement the measure in the full spirit of the legislation. Their concern is that insurers and managed-care firms have been able to successfully thwart similar state laws.
The Departments of Labor, Health and Human Services (HHS), and the Treasury are drafting regulations for the new law, and more than 400 groups, governments, and individuals provided input during the public comment period that ended in May. In a July 27 letter to the heads of the three agencies, Senators Al Franken (D-MN), Edward Kennedy (D-MA), Jack Reed (D-RI), and Sheldon Whitehouse (D-RI), wrote, "To avoid misinterpretation of the law and to ensure access to these critical services, it is imperative that you not only issue regulations according to clear Congressional intent but also address concerns submitted during the public comment period." The letter noted the importance of using regulations to clarify key questions about addiction and mental health scope of services, medical management, deductibles, and treatment limitations. "Without timely issuance of regulations that clarify Congressional intent, it is likely that health plans will implement the law according to their proposed version of regulations as set forth in their public comments," the senators wrote. They added, "Only with regulations can we ensure the end to discrimination against those with mental health and substance use disorders."
In May, the Parity Implementation Coalition — an advocacy group that includes the American Society of Addiction Medicine, the Betty Ford Center, Bradford Health Services, Faces and Voices of Recovery, the Hazelden Foundation, Mental Health America, the National Alliance on Mental Illness, the National Council for Community Behavioral Healthcare, the Watershed Addiction Treatment Programs, and Wellstone Action — submitted 44 pages of comments to the Department of Labor, which is taking the lead on parity regulations. Specifically, the comments stressed that to dissuade circumvention of the improvements intended by the law the regulations must ensure that medical financial requirements for mental health addiction services are no more restrictive than such techniques, limitations, and requirements for medical/surgical services. Also, the coalition noted that the "no more restrictive" standard applies to benefit rules about addiction and mental health medications, out-of-network coverage, and medical-management criteria (e.g., managed care rules). Finally, the coalition called for a Consumer Advocate Office to be established at the Departments of Labor and HHS to assist consumers who have questions about their rights and benefits under the law.
Comments from insurance and employer groups — e.g., the US Chamber of Commerce and the American Benefits Council (ABC), which represents Fortune 500 Companies — indicate a different interpretation of the law, particularly regarding the use of managed-care techniques to control benefits and costs and the extent to which addiction and mental-health benefits can be "separate but equal" compared to general medical coverage. In their comments, the Chamber of Commerce and ABC said, "The Act explicitly imposes parity requirements with respect to treatment limitations and financial requirements, as well as out-of- network coverage. The Act does not, however, expressly extend parity requirements to medical-management techniques. Since there is no explicit parity requirement for medical management in the Act, none should be implied in regulatory guidance by the agencies." The chamber, ABC, and similar groups also are seeking to retain the right to charge higher co-pays for addiction and mentalhealth care (using the argument that such providers are "specialists"), as well as the ability to exclude (under some circumstances) coverage of certain conditions, treatments, providers, and treatment settings.
The law requires the federal government to issue its parity regulations by October 3. If the draft regulations begin circulating in early September, as expected, advocates worry that will be too late for all three agencies to sign off on final regulations by the October deadline. They want to have sufficient time to review the regulations before they go into effect, and are hoping the regulators will move quickly. If they do not, it is possible the law could go into effect without regulations. In that case, it will end up in court.
FROM THE STATES . . .
Ohio Bill Provides for Increasing Nurse Faculty
With the Ohio Senate's passage of SB 89 by a unanimous vote (32-0) on July 13, it appears that the state's legislators have come to recognize that the reason Ohio, and the nation, are facing a major nursing shortage is not because qualified applicants for nursing school are in short supply. Rather, it is because schools do not have enough faculty members to teach them. While the large salary disparity between nurse faculty and nurses who work in a clinical setting does, to some extent, account for the difficulty in recruiting nurse educators, other issues, such as the high cost associated with being qualified to teach, also play a large part.
Ohio requires that nurse faculty have at least a master's degree, and preferably a doctorate. The cost of obtaining such degrees can run into tens of thousands of dollars and for many is prohibitive. Therefore, SB 89 aims to help nurses who want to teach, but cannot afford the schooling, by proposing a reallocation of loan funds under the Nurse Education Assistance Program. That program provides loans and often loan forgiveness for nursing students.
Another provision of SB 89 would allow APRNs from other states to practice in Ohio without being retrained. Such APRNs must have had prescriptive authority in the other state for at least one continuous year within the past three years.
The bill now awaits action by the Ohio House.