A Framework for Meeting the Challenges of Mental Health Parity

In theory, the concept of mental health parity appears simple and straightforward: if a healthcare organization wishes to offer mental health and substance use disorder (MHSUD) benefits, they must do so in parity with medical and surgical benefits. In practice, however, ensuring mental health parity poses substantial challenges to payer and provider organizations in terms of resources, diagnostic methods, and systems of care.

Mental health parity requirements originated from the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008[1], which built upon and added substance use disorder requirements to the Federal Mental Health Parity Act of 1996[2]. These requirements have since been revised and expanded upon through the 2010 Interim Final Rule (IFR)[3], the 2013 Final Rule[4], and other legislation, resulting in the movement toward mental health parity we know today.

The two greatest challenges in achieving mental health parity revolve around levels of care unique to mental health and substance use disorders (MHSUDs) and expanded requirements on quantitative and nonquantitative treatment limitations for MHSUD treatment. Both require innovative thinking and a framework for aligning the standards of MHSUD and medical/surgical benefits.

Levels of Care

While inpatient and outpatient classifications apply readily to both MHSUD and medical/surgical benefits, the intermediate levels of care (e.g. services less intensive than inpatient, but more expansive than is available in most outpatient clinics) have historically been managed in divergent ways. For medical and surgical patients, intermediate levels of care are generally not acute, and are not offered as alternatives to inpatient admission. In contrast, intermediate levels of care for MHSUD patients are designed as alternatives to inpatient care, and generally are meant to support acute care management. The complications resulting from this misalignment across MHSUD and medical/surgical levels of care pose a significant challenge to healthcare organizations in their efforts to achieve mental health parity.

Treatment Limits

Perhaps an even greater challenge to healthcare organizations has been developing a framework to avoid parity violations for quantitative and nonquantitative treatment limitations.

In essence, quantitative limits to MHSUD treatment – meaning anything that can be numbered, such as dollar caps on services – for the most part cannot be applied if there is no correlative limitation for medical or surgical benefits. Exceptions to this mandate have been alluded to in the IFR, Final Rule, and subsequent guidance statements from the Departments of Health and Human Services, Labor, and Treasury, though confusion remains. These documents provided numerous examples of “warning signs” of potential parity violations that were not absolute, and positive models (e.g. organizations whose utilization management models were identified as being within the bounds of parity) were not provided.

The mandate surrounding nonquantitative treatment limitations has, in many cases, proven to be even more difficult to develop a framework for, due to reasons intrinsic to the differences between physical health conditions and MHSUDs. Generally speaking, when determining the severity of medical and surgical conditions, the parameters are more objectively defined – consider the example of diabetic ketoacidosis, where specific acid/base and electrolyte levels in the patient’s blood are used for assessment. For MHSUDs, however, objective, widely-accepted laboratory parameters for diagnosis are not presently available. Rather, these determinations are made based on a combination of symptoms and functional impairment.

These determinations for MHSUD patients are further complicated when considering factors such as “likelihood of improvement” and “compliance with recommended therapies.” Although these considerations are standard to medical and surgical conditions, in the past, they have been used to discriminate against MHSUD patients, and are also considered “warning signs” of potential parity violations according to federal and state guidance. Providers must thus balance legitimate concerns related to discrimination with efforts to align mental and physical healthcare in the context of evidence-based medicine. In these efforts, clarity is hard to come by.

Achieving Parity

To support overcoming the considerable challenges of mental health parity, it is critical to have a consistent framework that approaches MHSUDs and medical/surgical conditions the same way. This guidance needs to be built on solid evidence and made accessible – or preferably, actionable – across the entire care continuum.

MCG Behavioral Health care guidelines align with mental health regulatory requirements in the MHPAEA and subsequent legislation. Across all MCG care guideline volumes, the development methods for MHSUD content are the same as medical and surgical content, supporting consistency with regard to quantitative and nonquantitative limitations. When evidence is available to provide guidance on the treatment appropriate for the management of behavioral health conditions, this is included in the same way for MHSUDs and medical/surgical care. Additionally, MCG includes guidance for acute care within five different levels of care, as well as for long-term community-based residential behavioral health care and custodial care. These levels of care span across the patient’s entire care journey and help to ensure parity with medical and surgical treatment.


MCG also aligns with criteria developed by the American Society of Addiction Medicine (ASAM) for substance use disorders, which is required in more than 30 states. ASAM criteria is referenced in MCG guidance, and MCG has no significant clinical deviations or deficits as compared with ASAM guidelines. In fact, healthcare organizations across the country have successfully implemented the use of MCG care guidelines even when ASAM mandates exist.

In addition, MCG offers evidence-based guidance for 16 diagnostic groups covering conditions such as autism and eating disorders. MCG also has the added benefit of being able to integrate into existing EMR and medical management software for a seamless clinical workflow.

To learn more about MCG Health solutions for mental health parity, click here.


Image courtesy Shutterstock/GrAl

[1] Fact Sheet: The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (PDF).

Employee Benefits Security Administration, US Department of Labor. January 29, 2010.

[2] Fact Sheet: The Mental Health Parity Act. Employee Benefits Security Administration, US

Department of Labor. October 2008.

[3] US Department of Labor. Interim Final Rules Under the Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008. Federal Register February 2,


[4] Internal Revenue Service, Employee Benefits Security Administration, Centers for Medicare

& Medicaid Services. Final rules under the Paul Wellstone and Pete Domenici Mental Health

Parity and Addiction Equity Act of 2008; technical amendment to external review for multi-state

plan program: final rules. Federal Register November 13, 2013;78(219), 68239–96.

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