This study confirms that special limits on behavioral health care continue to predominate, well after managed care became dominant in US health care. 90% of products had special annual limits for outpatient mental health care, whereas other surveys have found that general medical conditions are hardly ever subject to special limits (US Bureau of Labor Statistics, 2007
). The only limits widely used for general medical care are limits on lifetime spending, which one survey reported as applying to only half of covered workers in 2004, and being mostly in the $1 million-$2 million range (Kaiser Family Foundation, 2004
It is noteworthy that so many products have limits of 30 outpatient visits per year (or even lower) for MH and SA combined, given that many individuals have both MH and SA disorders concurrently, and may face an additional challenge getting both treated within 30 visits per year. National survey data indicate that among adults with serious psychological distress in the past year, 22% had past-year dependence or abuse of illicit drugs or alcohol. For adults without serious psychological distress, the rate of past-year dependence or abuse was 8% (Substance Abuse and Mental Health Services Administration, 2007
It is also interesting to note that outpatient limits appear more stringent for mental health than for substance abuse treatment. One might have expected tougher limits on substance abuse, given the general perception that it is more stigmatized, and that spending on it is viewed less favorably by the public, compared to MH treatment (Martin, Pescosolido and Tuch, 2000
). On the other hand, from a health plan point of view, SA disorders are considerably less prevalent. In addition, SA benefits may be seen as less vulnerable to discretionary use, given the extreme reluctance of many people to enter SA treatment unless coerced by employers, courts and others, and the unpleasantness of some SA treatments such as opiate detoxification (Barry and Sindelar, 2007
). The idea that SA treatment demand is less sensitive to generous benefits is also borne out by recent research finding that the effect of copays on treatment intensity is smaller for SA than had been found previously for MH (LoSasso and Lyons, 2004
MH also differs from SA in the extent to which medications have emerged as a major part of treatment: in 2003, they accounted for 23% of MH spending but only 0.5% of SA spending (Mark et al 2007a
). Spending on medications does not count toward the special limits described in this paper, so those limits would have less impact on patients receiving only periodic visits for medication monitoring (although their spending on drugs is managed using other techniques such as three-tier formularies) (Huskamp 2005
; Hodgkin, Horgan, Garnick et al., 2007
). However, a majority of treatment users have at least some ambulatory visits, amounting to 66% of users in 2001 (Zuvekas, 2005
). Plans may perceive a need for continued attention to visit costs, not least as the proportion of the population with any mental health treatment visits has increased over time.
Managed care is often viewed as having less need of benefit limits, given its access to other cost-containment tools such as utilization management and provider profiling (Barry, Frank, and McGuire, 2006
). In support of this, we find that out-of-pocket costs are lower in HMO and POS products, which are viewed as more managed than PPOs. This confirms Zuvekas and Meyerhoefer's (2006)
finding in national patient-level data, where HMO members had lower out-of-pocket share. However, our results suggest that despite having these other tools, managed care plans have not chosen to abandon benefit limits, perhaps because they perceive risks in doing so, or no gains. When the federal 1996 Mental Health Parity Act banned special limits on mental health spending, plans responded by replacing spending limits with limits on visits and days, rather than by abandoning limits altogether (Gitterman, Sturm, Pacula et al, 2001
). Barry and colleagues have suggested that plans may retain limits as a way to discourage enrollment of individuals likely to use mental health benefits (Barry, Gabel, Frank et al, 2003
State parity laws had little effect on expected out-of-pocket cost in our study, possibly due to the large number of employers that are exempted from state laws due to their small size or self-insured status (Buchmueller et al., 2007
The benefit limits we document here should mostly disappear under the new federal parity law that just passed. Where the 1996 law only banned special dollar limits for MH, the 2008 law adds a prohibition on other special limits such as for visits or episodes. In addition, the 2008 law applies to SA treatment too, where the 1996 law only covered MH. Finally, it prohibits the use of higher copays/coinsurance for MH/SA, which were allowed under the 1996 law, and affect many more patients than limits, since they must be paid even by low users who would not reach the limit. Like the 1996 law, the 2008 law includes exemptions for small employer groups (those with fewer than 50 enrollees).
However, elimination of special benefit limits will not necessarily remove all access barriers to BH care, depending on how health plans react. Some plans could drop BH benefits altogether, since the law still does not mandate BH coverage in private insurance. Alternatively, they could raise copayments and coinsurance – as long as the increases are for all care, not just BH care. This would mean the new law had less ability to reduce patient's out-of-pocket costs. Finally, plans could increase the stringency of their utilization management for BH care, for example by requiring more frequent reauthorization of treatment. The new law requires disclosure of plans' medical necessity criteria, but leaves various other management approaches up to the plan's discretion.
Continued monitoring of patients' access to BH treatment will therefore require supplementing benefits data with information on managed care plans' utilization management activities. This would allow a fuller picture of the state of patient access to MH/SA treatment. It will also be important to examine differences in out-of-pocket burden across socioeconomic groups.