April 01, 2022

ICYMI: At Hearing, Warren Urges Full Enforcement of Parity Laws Against Insurance Companies that Restrict Access to Behavioral Health Care

Warren Announces Plans to Reintroduce Her Behavioral Health Coverage Transparency Act to Audit Plans and Simplify Complaint Processes

Video of Hearing (Senator Warren at 02:52)

Washington, D.C. – In case you missed it, during a hearing of the Senate Finance Committee, United States Senator Elizabeth Warren (D-Mass.) called out insurers for creating barriers to behavioral health care for patients in need and announced that she would reintroduce her Behavioral Health Coverage Transparency Act to randomly audit insurers, ensure compliance with federal parity laws, and simplify complaint processes for patients to report parity violations.

Senator Warren described how insurance companies narrow provider networks, prolong approval processes, and subject services to other non-quantitative treatment limitations (NQTLs), which create barriers to behavioral health care. In response to Senator Warren, Dr. Andy Keller, from the Meadows Mental Health Policy Institute, confirmed that there are “dramatic gaps” between the coverage health that plans promise and the service that patients receive. He agreed that regulators should be required to audit more plans and have the authority to impose penalties on insurers for parity violations. 

At the hearing, Senator Warren announced plans to reintroduce her Behavioral Health Coverage Transparency Act, which would increase oversight and enforcement to ensure that insurance companies cover behavioral health benefits and services that are on par with physical health benefits and services, and comply fully with parity laws. The bill would also provide protections for patients so they have a simple complaint process to report parity violations.

Transcript: Behavioral Health Care When Americans Need It: Ensuring Parity and Care Integration
U.S. Senate Committee on Finance
Wednesday, March 30, 2022

Senator Elizabeth Warren: Thank you, Mr. Chairman. So in 2020, one in every five adults experienced mental illness. For substance use disorder, the figure was one in seven. And despite the critical need for mental health and substance use disorder services, few Americans get the treatment that they need. If you ask people experiencing mental illness if they got the help they needed, one in three said no. And just under 10% of adults experiencing substance use disorder were able to access treatment. 

Now there are a lot of factors that contribute to the degree of unmet behavioral health needs, but one of the most egregious is the way that insurance companies flout federal laws requiring them to provide this care. 

And a big way that insurers restrict access to behavioral health care is by more aggressively subjecting these services to what are called non-quantitative treatment limitations (NQTLs). I know you’re all familiar with these. 

So Dr. Ratzliff, let me start with you. You’ve seen this play out in your own practice. Can you explain how insurers use NQTLs to create barriers to behavioral health care, and what effect does this have on your patients? 

Anna Ratzliff, MD, Ph.D., Co-Director Of The Advancing Integrated Mental Health Solutions (AIMS) Center And Professor, University of Washington: Yeah so I’ll talk specifically, I’ve mentioned this example but I think one of the biggest factors that we’ve seen is actually having these ghost networks. I mean really not being able to actually call off of the list that you’re given and find someone that you can actually get care for. And this again, I think some people, you know, people are already struggling with depression and anxiety symptoms. It’s really hard to call multiple people over and over again and never get an answer or never get a response for treatment. So I think that’s one of the most, you know, egregious ways that I’ve seen that play out.

Senator Warren: So narrower provider networks, more and more phone calls that you’ve gotta make in order to get approval. And of course, the response here I assume is that patients delay care or give up altogether. So we’ve known about this problem for a long time. This is not the first time this has come to our attention. 

And in 2020, Congress passed legislation to give federal agencies enforcing our parity laws more tools to evaluate insurance companies’ use of these practices. Now the law also required regulators to review at least 20 plans each year to assess for compliance. In a report released earlier this year, the Department of Labor, the Department of Health and Human Services, and Treasury stated that the specific plans selected for such review were chosen based on existing investigative leads or open investigations into reported violations. 

So Mr. Dicken, if I can, I want to ask you, you run the health care team at the federal government’s watchdog unit, the Government Accountability Office, and you’ve looked into this issue. If we’re trying to understand if insurance companies are following federal parity laws, does it make sense to look only at insurers that have received complaints? 

John Dicken, Director, Health Care, United States Government Accountability Office: Thank you, Senator Warren. No, we’ve raised concerns that by only focusing on either complaints or other targeted reviews of health plans, that that leaves risk that there could be other plans that are not, there are a number of reasons why consumers may not be making complaints or be aware of the requirements. 

Senator Warren: Thank you. And you know, I agree with you on this, I agree we need to monitor all plans for compliance with our parity laws. You know it’s the same reason a teacher might give a pop quiz. Instead of just focusing on a handful of students who didn’t turn in their homework. You give it to the whole class to find out who’s doing great, who’s having a little trouble, and who is in big trouble, but you only get that if you’re able to reach all the way across.

Now, Dr. Keller, we’re not going to make insurance companies take pop quizzes, but we can do randomized audits. So how would requiring federal enforcers to conduct randomized audits of plans strengthen efforts to identify and eliminate unequal application of NQTLs?

Andy Keller, Ph.D., President and CEO, Linda Perryman Evans Presidential Chair, Meadows Mental Health Policy Institute: Well I think you explained it, actually, quite well because I think, really, these are across the board and the sad reality is that every plan that’s been reviewed so far has dramatic gaps. So the only way we’re going to be able to enforce across all those plans is if all of them know that there’s a possibility and also that they know that there’s a significant possibility. So I would argue we need to actually do more than 20. We need to also make sure that they’re more in depth and we need to expand the penalties aligned with them so that in addition to having the test, the test has consequences for the final grade. 

Senator Warren: Thank you very much for that answer. Just focusing on the parity violations, we know that these are dramatically under-reported. We cannot rely on complaints as the only signal that an insurer is breaking the law. I believe in randomized audits.

And that’s why I’ll be reintroducing my Behavioral Health Coverage Transparency Act to require federal enforcement agencies to conduct randomized audits of plans and at the same time to simplify the complaint process which makes it easier for patients to report parity violations. 

Health care – including behavioral health care – is a human right, and we must ensure that Americans don’t face any additional barriers to getting the often life-saving care that they need. 

So thank you all for your work. I very much appreciate it. I know your patients appreciate it and thank you for being with us today. 

Thank you.