Enforcement of the Mental Health Parity and Addiction Equity Act: State Insurance Commissioners' Statutory Capacity.

OBJECTIVE: State insurance departments enforce the federal Mental Health Parity and Addiction Equity Act (MHPAEA) for fully insured employer-sponsored health plans and plans on the individual marketplace. Variable enforcement among states may drive patients' difficulties in accessing behavioral health treatment. This study explored insurance commissioners' statutory capacity for enforcing the MHPAEA. METHODS: Legal mapping of insurance office powers and responsibilities was conducted for MHPAEA-enforcing states. Relevant state laws and regulations were gathered from the Westlaw database. Sections were coded in the categories commissioner selection, frequency of examinations, fines, licenses, subpoenas, investigations and hearings, rehabilitation or liquidation of insurers, and initiation of legal actions. RESULTS: The sample included 450 sections of states' codes and regulations. The 46 states that enforced the MHPAEA showed only small differences in the powers and responsibilities of insurance commissioners. CONCLUSIONS: Similarities across states in statutory capacity of commissioners suggest that it is not a primary source of variation in MHPAEA enforcement.

Factors Affecting State-Level Enforcement of the Federal Mental Health Parity and Addiction Equity Act: A Cross-Case Analysis of Four States.

CONTEXT: The Mental Health Parity and Addiction Equity Act (MHPAEA) requires coverage for mental health and substance use disorder (MH/SUD) benefits to be no more restrictive than for medical/surgical benefits in commercial health plans. State insurance departments oversee enforcement for certain plans. Insufficient enforcement is one potential source of continued MH/SUD treatment gaps among commercial insurance enrollees. This study explored state-level factors that may drive enforcement variation. METHODS: The authors conducted a four-state multiple-case study to explore factors influencing state insurance offices' enforcement of MHPAEA. They interviewed 21 individuals who represented state government offices, advocacy organizations, professional organizations, and a national insurer. Their analysis included a within-case content analysis and a cross-case framework analysis. FINDINGS: Common themes included insurance office relationships with other stakeholders, policy complexity, and political priority. Relationships between insurance offices and other stakeholders varied between states. MHPAEA complexity posed challenges for interpretation and application. Policy champions influenced enforcement via priorities of insurance commissioners, governors, and legislatures. Where enforcement of MHPAEA was not prioritized by any actors, there was minimal state enforcement. CONCLUSIONS: Within a state, enforcement of MHPAEA is influenced by insurance office relationships, legal interpretation, and political priorities. These unique state factors present significant challenges to uniform enforcement.