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Missouri Will Become Last State To Enforce Federal Laws On Mental Health Care Coverage

Flanked by state lawmakers, Gov. Mike Parson signs House Bill 604 into law on July 7, 2021.
Missouri Governor's Office
Flanked by state lawmakers, Gov. Mike Parson signs House Bill 604 into law on July 7, 2021.

A new law will give the Department of Commerce and Insurance greater oversight to ensure mental health care is covered the same as physical conditions.

Under a new state law that went into effect late last month, Missouri will become the final state to enforce a federal law designed to ensure mental health care is covered by insurance providers the same as treatments for physical ailments.

The provisions were included in House Bill 604, an omnibus insurance bill sponsored by Rep. Kurtis Gregory, R-Marshall, that was signed into law by Gov. Mike Parson in July. The provisions enforcing the federal law will apply to insurance providers starting Jan. 1, 2022.

Initially filed as standalone bills by Kansas City Democrats Sen. Greg Razer and Rep. Patty Lewis, the measures codify in state statute that health insurance plans must meet the requirements of the Mental Health Parity and Addiction Equity Act of 2008.

Signed into law by former President George W. Bush, the landmark federal law stipulated that health insurance plans cannot impose dollar limits or restrictions on mental health treatments, including substance use disorders, that are greater than those for other physical medical conditions.

But advocates have argued that insurers have found loopholes to exploit and regulation is primarily in the hands of the states.

A lack of enforcement could result in patients being denied coverage for mental health services and greater costs shifted to taxpayers and programs like Medicaid as mental health issues are exacerbated, said David Lloyd, a senior policy advisor with The Kennedy Forum, which tracks the federal law’s enforcement nationwide. The nonprofit was founded in 2013 by former Congressman Patrick J. Kennedy, who was the lead sponsor of the federal act.

Lloyd said “it’s better late than never” that Missouri is incorporating the federal law into state statute, which will allow greater enforcement.

“This is a really important step,” Lloyd said, “because it was almost a little bit of a no man’s land, in terms of who was in charge of oversight of commercial insurance plans that are fully insured.”

According to a 2019 U.S. Government Accountability Office (GAO) report assessing the law’s enforcement, states varied in the frequency and type of reviews conducted and at a federal level it was unclear if oversight strategies were effective.

At the time, a survey by the GAO found that Missouri and Wyoming were the only two states that did not report that they conduct reviews for parity compliance before plans were approved for sale in their states. Centers for Medicare & Medicaid Services and the U.S. Department of Health & Human Services were also responsible for parity enforcement in four states, including Missouri and Wyoming, according to the report.

While Missouri just signed into law the enforcement of the federal act, other states, like California, have gone further and passed laws aimed at closing the law’s gaps.

Lewis, a former intensive care unit nurse and health care executive, said she has had people reach out who have been only allowed a limited number of visits to their therapist.

“Mental health is a chronic condition. So just like if you have a cardiac condition, you can go see your cardiologist as much as you need to. There’s no lifetime or annual limit,” Lewis said. “It’s not like… ‘You’ve gone to your cardiologist three times. Now you’re done. You’re cut off.’ But that’s what we see with mental health.”

It’s a similar issue Razer said he has heard from meetings with Kansas City firefighters who said they had limits on the number of times they could see a mental health professional “regardless of what kind of trauma they may have had.”

Razer said he first became aware of the issue after a member of his staff heard a 2019 KCUR story detailing the state’s lack of action and the effects it was potentially having on Missourians in immediate need of services. Razer and Lewis said the pandemic has only exacerbated the need for accessible mental health treatment as reports of anxiety, depression and suicidal thoughts are on the rise.

“Hopefully, this is just another recognition moving forward, that mental health is simply a health condition,” Razer said.

Razer and Lewis said compromises had to be reached with health insurance providers. Some exceptions to the plans covered include short-term plans 12 months or shorter, plans prior to the Affordable Care Act that didn’t include mental health coverage or other supplemental policies the Department of Commerce and Insurance (DCI) director determines.

“They’re in business to make money, and we were asking them to provide appropriate services,” Razer said of health insurance providers.

Shannon Cooper, a lobbyist for America’s Health Insurance Plans, testified on Lewis’ bill in committee in April and said insurers weren’t against the legislation. But he cautioned lawmakers codifying federal regulations that can change “numerous times” and may be difficult for DCI to keep up with.

Brandon Koch, the executive director of the Missouri Insurance Coalition, which represents members like health insurance carrier Blue Cross/Blue Shield of Missouri, said the coalition did not have an issue with the provisions regarding mental health parity. Koch said he could not comment on the enforcement actions DCI may take and stressed the coalition’s members will continue to comply with state and federal laws.

“The amendment largely codified federal law that our member companies were already following, and it includes appropriate exceptions for certain health policies,” Koch said. “The language seemed to garner broad support from legislators on both sides of the political aisle and should be good for Missouri consumers.”

DCI said Missourians shouldn’t see a difference in the mental health services covered under their insurance plans as providers have been required to comply with the federal law since its passage in 2008.

However, the bill “will enhance the Department’s authority to protect consumers, by allowing it to also enforce the federal law,” said Lori Croy, a spokeswoman for the department.

Croy said much of implementation will involve internal training. DCI has not yet identified a need to promulgate state rules, Croy said, and has reached out to the U.S. Department of Health and Human Services to begin communication and coordination.

Lloyd said the Missouri bill “sets a floor” and that aggressive oversight is needed to ensure health insurance plans are in compliance, like assessing plans for parity before they’re sold, investigating complaints for parity violations that consumers may not be aware of and looking at plans’ parity compliance analyses to ensure they demonstrate compliance.

“It’s not enough for you just to have a parity compliant policy on paper,” Lloyd said, “and then as you administer it, you make decisions that discriminate against people with mental health and addiction challenges.”

Lloyd pointed to states like Texas and New York as examples of states taking strong enforcement action. Last month, New York Attorney General Letitia James and the U.S. Department of Labor announced a more than $15 million settlement reached with UnitedHealthcare over allegations the health insurer illegally limited coverage of outpatient psychotherapy.

While it remains to be seen what enforcement action may look like in Missouri, Lewis said she hopes the department is transparent about actions it takes.

“I firmly believe lives are at stake,” Lewis said.

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