Approximately 2 percent of employers reported that they offered coverage  for only mental health conditions in 2008 but not substance use disorders,  and continued to offer coverage for only mental health conditions in the  current plan year. Conversely, a small percentage of employers—about 2 percent of those  employers that responded to our survey about their coverage of MH/SU  for both plan years—reported discontinuing their coverage of both MH/SU  or only substance use disorders in the current plan year. Published employer surveys also reported that few employers  discontinued coverage of MH/SU since MHPAEA was passed. However, fewer employers  reported excluding at least one broad MH/SU diagnosis and more  employers reported excluding a treatment related to MH/SU in the current  plan year than for 2008. The types of MH/SU diagnoses included and excluded from employers’  MH/SU benefits remained consistent between the current plan year and  2008. Of the employers that responded to our survey question about the  diagnoses included in their MH/SU benefits for both the current plan year  and 2008 plan year, 34 percent reported that their most popular plan in  their current plan year excluded at least one broad MH/SU diagnosis from  their benefits, and 39 percent reported this for the 2008 plan year. The most common change to MH/SU benefits reported among those that  responded to our survey was enhancing benefits through the removal of  treatment limitations, such as the number of allowed office visits or  inpatient days. Reported use of lifetime dollar limits on MH/SU treatments also declined  from 2008 to the current plan year.answered detailed benefits questions in our survey reported lifetime dollar   About 5 percent of employers that  limits on treatments for MH/SU for the current plan year, compared to   20 percent in 2008. Among employers who reported information on cost-sharing, copayments  and coinsurance amounts for office visits with in-network providers  generally stayed about the same, fluctuating minimally from 2008 to the  current plan year, while copayments and coinsurance amounts for  outpatient services with in-network providers decreased slightly from  2008 to the current plan year (see table 1). Employers May Continue to Modify Benefits as Agencies Refine Parity Requirements

Employers may continue to modify certain nonfinancial requirements— such as changes to the services they cover (the scope of services) and  NQTLs—in their MH/SU benefits in response to agencies’ issuance of  final implementing regulations for MHPAEA. Agency officials reported that  the final regulations may provide additional detail on the required scope of  services and on using NQTLs. Research also indicates that health  insurance coverage for MH/SU has had mixed effects on access to, and  use of, MH/SU services. In addition, little research has explored the effect  of health insurance coverage for MH/SU on health status. Research Indicates That Enhanced Health Insurance Coverage for Mental Health Conditions and Substance Use Disorders Reduces Enrollee Expenditures

Of the nine studies we reviewed that focused on the effect of health  insurance coverage for MH/SU on enrollee expenditures, six studies  generally found that the implementation of parity requirements led to  reduced enrollee expenditures. For example, one of these studies examined the  effect of a state parity requirement within the first 3 years following  implementation of parity requirements, and found that the  implementation of parity requirements resulted in increased access to,  and use of, mental health services; however, the implementation of  parity resulted in reduced access to substance use disorder  services.increased access to, or use of, MH/SU services for individuals with  mild to moderate mental health needs, but that state parity   Another study found that state parity requirements  requirements had no effect on access to, or use of, MH/SU services  for individuals with severe mental health needs. Little Research Has Explored the Relationship between Health Insurance Coverage and Health Status

Of the studies we reviewed, two studies examined the effect of health  insurance coverage for MH/SU on health status of the general population. Agency Comments

DOL and HHS reviewed a draft of this report and provided technical  comments, which we incorporated as appropriate. Given the response rate, our survey results are not  generalizable. Rather, the survey responses provide information limited to  responding employers’ coverage of MH/SU in the current plan year and  2008 plan year. We spoke with agency officials from the Department of  Labor (DOL), Department of Health and Human Services’s (HHS)  Assistant Secretary for Planning and Evaluation (ASPE), and HHS’s  Substance Abuse and Mental Health Services Administration who had  expertise in MH/SU issues. We also interviewed  four employer survey respondents—one in each employer size  category—to obtain more detailed information about the employers’  coverage of MH/SU, and their reasons for making or not making changes  to coverage after the Paul Wellstone and Pete Domenici Mental Health  Parity and Addiction Equity Act of 2008 (MHPAEA) took effect. Appendix II: Articles Reviewed on the Effect of Health Insurance Coverage on Enrollees

We conducted a review of published studies between January 2000 and  March 11, 2011, that included an assessment of the effect of health  insurance coverage for mental health conditions and substance use  disorders (MH/SU) on enrollee expenditures, access to, or use of, MH/SU  services, or health status.
Why GAO Did This Study

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that employers who offer health insurance coverage for mental health conditions and substance use disorders (MH/SU) provide coverage that is no more restrictive than that offered for medical and surgical conditions. Employers were required to comply with the law for coverage that began on or after October 3, 2009. The Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Department of the Treasury share oversight for MHPAEA. MHPAEA also requires GAO to examine trends in health insurance coverage of MH/SU. This report describes (1) the extent to which employers cover MH/SU through private health insurance plans, and how this coverage has changed since 2008; and (2) what is known about the effect of health insurance coverage for MH/SU on enrollees' health care expenditures; access to, or use of, MH/SU services; and health status. GAO surveyed a random sample of employers about their MH/SU coverage for the most current plan year and for 2008. GAO received usable responses from 168 employers--a 24 percent response rate. The survey results are not generalizable; rather, they provide information limited to responding employers' MH/SU coverage. GAO reviewed published national employer surveys on health insurance coverage and interviewed officials from DOL, HHS, and other experts. GAO also reviewed studies that evaluated the effect of MH/SU coverage on enrollees' expenditures, access to, or use of, MH/SU services, and health status.

What GAO Found

Most employers continued to offer coverage of MH/SU since MHPAEA was passed. Of the employers that responded to GAO's survey, 96 percent offered coverage of MH/SU for the current plan year and for 2008, before MHPAEA was passed. Approximately 2 percent of employers reported offering coverage for only mental health conditions but not substance use disorders for the current plan year and for 2008. Conversely, about 2 percent of employers reported discontinuing their coverage of both MH/SU or only substance use disorders in the current plan year. The types of MH/SU diagnoses included and excluded in employers' MH/SU benefits remained consistent between the current plan year and 2008. Of the employers who provided information about diagnoses included in their MH/SU benefits for both the current plan year and 2008, 34 percent reported that their most popular plan in the current plan year excluded at least one MH/SU diagnosis from their benefits, and 39 percent of employers reported excluding at least one MH/SU diagnosis from their benefits for the 2008 plan year. The most common change to MH/SU benefits reported among those who responded to the survey was enhancing benefits through the removal of treatment limitations, such as the number of allowed office visits. Reported use of lifetime dollar limits on MH/SU treatments also declined from 2008 to the current plan year. Among employers who reported information on cost-sharing, copayments and coinsurance amounts for in-network providers generally stayed about the same, fluctuating minimally from 2008 to the current plan year. Published national employer surveys on health insurance coverage also reported results consistent with GAO's survey data. Employers may continue to modify certain nonfinancial requirements--such as changes to the services they cover (the scope of services) and nonquantitative treatment limits--in their MH/SU benefits in response to agencies' issuance of final implementing regulations for MHPAEA. Officials from DOL and HHS reported that the final regulations may provide additional detail on these nonfinancial requirements. Research suggests that coverage for MH/SU has a varied effect on enrollees. Research examining the effect of health insurance coverage for MH/SU on enrollee expenditures generally found that the implementation of parity requirements reduced enrollee expenditures. Studies that examined the effect of health insurance coverage for MH/SU on enrollee access to, and use of, MH/SU services had mixed results, with some studies indicating there was little to no effect and others indicating that there was some effect--such as finding that restricting coverage had a negative effect on use of services. Little research has explored the relationship between health insurance coverage and health status. Of the studies we reviewed, two examined the effect of health insurance coverage for MH/SU on enrollee health status and found different effects. GAO provided a draft of the report to DOL and HHS. Both agencies provided technical comments, which have been incorporated as appropriate.