a bill pending in the US Congress to require parity between
mental and physical health benefits. The bill is a follow up to similar
legislation passed in 1996, which was severely limited in scope: Employers did
not have to provide any mental-health benefits. Copays and deductibles could be
higher for mental-health expenses. Visits could be limited. And small
businesses and self-insured employers which cover healthcare costs directly
were entirely exempt. Not exactly my understanding of the word "parity."
Full Parity for Mental Illnesses expands the Mental Health Parity Act of 1996 (MHPA) to
prohibit a group health plan from imposing treatment limitations or financial
requirements on the coverage of mental health benefits unless comparable
limitations are imposed on medical and surgical benefits.
a summary of the pending bill prepared by the National
Alliance for the Mentally Ill:
[The proposed legislation] provides full
parity for all categories of mental disorders, including schizophrenia, bipolar
disorder, major depression, obsessive-compulsive disorder, and severe anxiety
disorders. Coverage is also contingent on the mental illness being included in
an authorized treatment plan, the treatment plan is in accordance with standard
protocols and the treatment plan meets medical necessity determination
Defines "treatment limitations" as limits on the frequency of
treatment, the number of visits, the number of covered hospital days, or other
limits on the scope and duration of treatment and defines "financial
requirements" to include deductibles, coinsurance, co-payments, and
Eliminates the September30, 2001 sunset provision
in the MHPA. Like the MHPA, the bill does not require plans to provide coverage
for benefits relating to alcohol and drug abuse. There is a small business
exemption for companies with 25 or fewer employees.
No Parity in Comp
Parity is an
important concept, but one that simply does not exist in the workers comp
system. Comp carriers habitually reject any claims for benefits based upon
work-related mental disability (post traumatic stress syndrome, stress in
general, depression, etc.). The insurer strategy is usually "Deny, Deny, Deny"
until a judge orders otherwise.
There are a number of reasons for this virtually universal
aversion to accepting mental disability claims:
: The standards for
eligibility in most states are very high: work must be the predominant
cause of the disability. Most of us have plenty of stress in our lives
away from work.
NOTE: Long gone are the days when in order for a claim to
be compensable under comp, California required a mere 10 percent of the stress
to be work related!
: Comp benefits tend to be very open ended. Once the
carrier accepts a (mental health-based) claim, they are likely to own it
forever. As a result, they usually start by rejecting the claim.
physical injuries, where objective criteria for treatment and recovery are
often (but not always) straight-forward, the end-point for a mental disability
can be very elusive.
: managed care can limit treatment for open-ended
physical problems (requiring, for example, limited physical therapy,
chiropractic visits, etc). Similar limits on mental health treatment (up to and
including hospitalization) are more difficult - but not necessarily impossible
- to impose.
It's unfortunate that comp turns its back on the mental
aspects of injury. Over the years we have seen many claims where a little
counseling after the injury could significantly speed recovery. Well-structured
groups could provide support to workers recovering from injuries at a very
modest cost. As a culture, we have no problem treating physical disabilities,
but when it comes to issues of mental health, we balk. Ironically, as often as
not the mental barriers to recovery trump the physical. Out-of-work employees
often succomb to depression - and once that happens, full recovery and return
to productive employment are much less likely to occur.
Ultimately, it's a matter of who pays, how much and when.
The enormous cost of losing a productive worker is seldom factored into the
equation. While Congress is about to force the parity issue on employers and
insurers for conventional health coverage, no such pressure is pending - or is
even foreseeable - for the workers comp system.
Posted by Jon Coppelman at 1:36