- Office of Attorney General Maura Healey
Media Contact for AG Healey Announces Groundbreaking Agreements that Expand Access to Behavioral Health Services for More Than One Million Residents
Boston — Attorney General Maura Healey has reached groundbreaking agreements with five health insurance companies and two companies that manage behavioral health coverage for insurers that will provide more than one million Massachusetts residents with improved access to behavioral health services.
The five assurances of discontinuance, filed today in Suffolk Superior Court, involve Harvard Pilgrim Health Care and United Behavioral Health d/b/a Optum; Fallon Community Health Plan and Beacon Health Strategies; AllWays Health Partners; Blue Cross Blue Shield of Massachusetts (BCBS); and Tufts Health Plan. The settlements are a result of AG Healey’s investigation into the companies’ compliance with behavioral health parity laws, as well as the accuracy of health insurers’ provider directories.
“Treatment for substance use disorder and access to therapy are vital to public health, but too many people are facing unlawful barriers to the care they need,” said AG Healey. “These companies are making substantial and unprecedented changes to help ensure patients don’t have to struggle to find behavioral health services in Massachusetts.”
Today’s announcement will result in a range of assurances to improve access to behavioral health care. In their settlements with the AG’s Office, three insurance companies – Harvard Pilgrim, Fallon, and AllWays – have resolved claims that they violated the Mental Health Parity and Addiction Equity Act and have agreed to change, or have already changed, how they determine reimbursement rates for outpatient behavioral health services. These insurance companies have also agreed to limit prior authorization for certain behavioral health care. In addition, all of the companies have agreed to make extensive changes to their provider directories to allow members to more easily reach behavioral health care providers.
The Mental Health Parity and Addiction Equity Act (the Parity Act) generally requires a health insurer to apply similar rules to mental health benefits as it does to medical and surgical benefits. The goal of the law has been to remove barriers that impede patients’ access to behavioral health care, like therapy and addiction treatment. The law applies to a range of treatment limitations that affect the scope or duration of behavioral health benefits, including provider reimbursement rates and requirements that patients obtain authorization from their health plan before receiving certain health care services.
Reimbursement Rate Disparities
Recent studies have reported significant disparities in payment rates for behavioral health providers compared to physical health providers, including a 2019 study that analyzed actual payment rates for commonly-used billing codes for office visits and found that primary care physicians in Massachusetts are paid 60 percent higher than behavioral health providers when providing comparable services using the same codes. Behavioral health providers have consistently cited low reimbursement rates as a primary reason they do not accept some insurance plans. If the providers do not accept insurance, patients must pay for their services out of pocket, which many patients cannot afford. With so many providers deciding they won’t participate in health plan networks because of low payment rates or administrative burdens, patients that need to rely on their insurance coverage to pay for services have a hard time finding providers who are “in network” for their health plan.
The settlements reached with Harvard Pilgrim, Fallon, and AllWays allege that each insurance company violated the Parity Act by using methods to determine provider reimbursement rates that resulted in lower payments for outpatient behavioral health services than for comparable physical health services. The companies have agreed to change, or have already changed, the way they establish their minimum reimbursement rates for in-network behavioral health outpatient services at all provider levels – including psychiatrists, psychologists, and social workers – generally resulting in higher reimbursement rates for such services.
Unnecessary Authorization Requirements
Harvard Pilgrim, Fallon, and AllWays have also agreed to change the way they manage certain behavioral health services, resolving claims by the AG’s Office that they imposed unlawful barriers, including prior authorization requirements, for behavioral health services that were not required for comparable physical health services and could not be justified under the Parity Act.
Under the terms of its settlement, Fallon, through its administrator Beacon Health Strategies, will no longer require prior authorization for routine behavioral health office visits or for inpatient mental health admissions after treatment in an emergency department.
Harvard Pilgrim and AllWays, through their administrator Optum, have agreed that for routine behavioral health visits, they generally will not overrule health care providers’ decisions on what constitutes appropriate care, including decisions about the appropriate type of treatment and frequency of visits.
The settlements reached with Harvard Pilgrim and BCBS also resolve allegations by the AG’s Office that the companies unlawfully imposed prior authorization requirements on certain patients who sought substance use treatment out of network or outside Massachusetts, in violation of state laws requiring insurers to cover certain substance use disorder treatment without prior authorization.
Several national studies have shown problems with health insurance companies’ provider directories. A November 2018 report from the U.S. Department of Health and Human Services found that nearly half of provider directories for Medicare Advantage plans displayed missing or inaccurate information, including claims that providers were accepting new patients when they were not. A separate report released on December 11, 2018 by the Blue Cross Blue Shield of Massachusetts Foundation found that 38.7 percent of those surveyed went without needed behavioral health treatment in the last year and that for most patients who had difficulty accessing behavioral health care, the problem was that providers either did not accept their insurance or their practices were closed to new patients.
Harvard Pilgrim, AllWays, Fallon, Optum, Beacon, Tufts and BCBS will each improve the accuracy of information in their provider directories and make changes to allow their members to more easily identify and reach behavioral health care providers for appointments. These changes include regular and robust provider directory audits, timely correction of inaccurate information in the directory – including information identifying providers’ availability to see new patients – and the tracking and resolution of complaints concerning directory inaccuracies.
In addition to the assurances made in today’s settlements, the companies will pay a combined total of nearly $1 million to a fund that will be used by the AG’s Office to promote initiatives designed to prevent or treat substance use disorders, increase access to behavioral health care services, or otherwise assist Massachusetts behavioral health care patients.
Today’s announcement is part of AG Healey’s ongoing work to address behavioral health parity and improve access to behavioral health care. In December 2018, the AG’s Office reached a settlement with Aetna Health Insurance Company, resulting in the company improving the accuracy of online directories and transparency of policies related to prior authorization.
The settlements announced today were handled by Assistant Attorneys General Lisa Gaulin, Tara Ruttle, and Matthew Berge, Former Assistant Attorney General Stephen Vogel, and Mediator Anna Everett, with assistance from Division Chief Eric Gold of the AG’s Health Care Division and Marlee Greer of the Civil Investigations Division.
STATEMENTS OF SUPPORT
“It was twenty years ago that the state enacted its mental health parity law. It is time to implement parity for what it is: behavioral health on the same terms and conditions with physical health,” said Health and Human Services Secretary Marylou Sudders. “The result of the Attorney General’s investigations will help ensure that parity and improve access for individuals seeking behavioral health treatment. Behavioral health is at the heart of Governor Baker’s health care bill, which proposes important shifts in our system that will enable us to address access, affordability and availability, and will ensure Massachusetts’ continued leadership in healthcare.”
“The agreements announced today address three important barriers to access – reimbursement rates, prior authorization requirements and the adequacy of provider panel lists,” said Marty Cohen, MetroWest Health Foundation President and CEO. “By focusing on these barriers, the Commonwealth and its health insurance plans are acknowledging that we can and must do better. Attorney General Healey and her staff are to be commended for taking on the issue of mental health parity and seeing it through with such positive results. While there is still more do be done to ensure true mental health parity and improved access to care, these actions will certainly bring us closer to that goal.”
“The Attorney General’s efforts represent a significant step forward in access to behavioral health services for Massachusetts consumers,” said Amy Rosenthal, Executive Director of Health Care For All. “Our HelpLine receives many calls each year from individuals who cannot find behavioral health services for themselves and their families. The settlement complements ongoing work to increase the accuracy of provider directories, as well as to address issues that will be helpful to bring more behavioral health providers into health insurance networks.”
“Social workers are on the front lines in Massachusetts, treating and serving the state’s most vulnerable, yet reimbursement rates for this crucial workforce do not allow many social workers to earn a living wage,” said Rebekah Gewirtz, Executive Director of the National Association of Social Workers, MA Chapter. “We applaud Attorney General Healey for her commitment to the people of our state across the income and geographic spectrum served by social workers, and her sustained commitment to those working in the mental health field who have been undervalued and, frankly, taken advantage of for far too long. The settlements announced today mark an important step forward for access to mental health services in Massachusetts.”
“Health Law Advocates works with consumers every single day who struggle to access mental health care far more than other types of care even though we have strong protections in the law meant to ensure equitable access to mental health services,” said Wells Wilkinson, Senior Staff Attorney with Health Law Advocates. “While the existing parity laws are critically important, Attorney General Maura Healey’s ongoing and strong commitment to enforcing the parity laws shows that there is still much work to do to ensure consumers can access mental health care when needed.”
“The Massachusetts Psychiatric Society applauds Attorney General Healey for her admirable work to help the residents of the Commonwealth gain access to treatment and knowledge and transparency about their mental health and substance use benefits,” said Marilyn Price, MD, President, Massachusetts Psychiatric Society. “The mental health parity investigation is a tremendous endeavor. Persons seeking mental health care should have the same access to timely care as they would with any other illness.”
“NAMI members and families are often the people on the front lines dealing with our mental health system and encountering barriers to accessing mental health services,” said Monica Luke, Board Chair, Advocacy Committee, NAMI Mass Board of Directors. “When insurance carriers do not provide coverage for mental health services on a par with physical health care, they are discriminating against those with a mental health condition. The barriers to access and reimbursement policies of insurers drive hundreds of business decisions by providers that have led to fewer beds, fewer mental health providers and numerous other barriers to care for many years. We are grateful to the Attorney General for her leadership in improving access to mental health services and ensuring compliance with our parity laws and addressing these barriers.”
“Parity for consumers who need to access mental health and addiction treatment remains an urgent challenge in Massachusetts,” said Lydia Conley, President and CEO of the Association for Behavioral Healthcare. “ABH and our members are grateful that Attorney General Healey has aggressively pursued action to right the lack of transparency and address needless barriers to care in the health care system.”