Access to Behavioral Health Services in Marketplace Plans in New Jersey: The Puzzle of Parity

Abstract

The Sentinel Project at Seton Hall Law School set out to assess access to care through the Affordable Care Act (ACA) in New Jersey. The Project’s goals are to evaluate whether the ACA’s promising market reforms are fully implemented in the State and throughout the nation, and to understand how gaps in implementation may be filled. In this Report, we focus on access to behavioral health (BH) care in healthcare coverage available through the federal Marketplace, or Exchange, in New Jersey. BH services, which include mental health (MH) and substance use disorder (SUD) services, are among the ten essential health benefits (EHBs) identified by the ACA that must be provided in qualified health plans (QHPs) available in the Marketplace. Through focused interviews, we identified a number of potential barriers to BH care in the State, including network adequacy and utilization management (UM) techniques. These barriers, however, are subject to the requirements of the ACA’s market reforms, which include its anti-discrimination provisions and the requirements of the federal Mental Health Parity and Addiction Equity Act (MHPAEA). Robust monitoring and enforcement of anti-discrimination and parity requirements, therefore, hold great promise for improving access to BH services. Regulators, carriers, providers, advocates, and patients alike, however, are wrestling with how best to implement these requirements. Parity, in particular, has been a decidedly vexing challenge for stakeholders. It is critical to solve the puzzle of parity to ensure beneficiaries can access the BH benefits that the ACA secures as essential.

Keywords: Affordable Care Act, ACA, PPACA, Essential Health Benefits, Medical Necessity, Discrimination, Parity, Network Adequacy, Appeals. Coverage Denials, Access to Care. Covered Benefits, Utilization Management, Formularies, Regulatory Filings, NQTLS, Nonquantitative Treatment Limits, Exchanges