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Report: Patients less likely to get behavioral health covered by insurance than other needs

A view of the Maryland State House in December 2021. Photo by Danielle E. Gaines.

Maryland health officials often tout the state’s relatively low 6% uninsured rate, but a new report shows that even the state’s insured population can struggle to receive coverage for a major component of overall well-being: behavioral health services.

Marylanders who seek behavioral health professionals such as psychiatrists and psychologists are more likely to have to look “out-of-network” than they would for most other health services, according to a new report from a nonprofit research institute called RTI International.

Receiving services “out-of-network” means that someone received services or went to medical professionals for treatment or counseling that were not covered by their insurance plans, which can be a significant cost burden.

Ensuring that people have the same access to mental health services as they would general health services is a federal requirement under the Mental Health Parity and Addictions Equity Act (MHPAEA) of 2008.

MHPAEA was originally applied to group health plans, but amendments in the Affordable Care Act of 2010 applied the requirement to individual health plans too, according to the federal Centers for Medicare and Medicaid Services (CMS).

The report, called “Behavioral Health Parity – Pervasive Disparities in Access to In-Network Care Continue,” found that in Maryland, and nationwide, patients still struggle to access in-network behavioral health care compared to similar services in traditional medical and surgical settings.

The report used data from 2019 to 2021 from one of the “largest commercial insurance claims databases to evaluate a key measure of health plan benefits that indicates whether individuals can access in-network behavioral health treatment as readily as medical/surgical treatment: the rate of use of out-of-network behavioral health providers.”

They found that most states do not have “parity” in access for behavioral health services.

“Patients went out-of-network 3.5 times (13.4% as compared to 3.8%) more often for all behavioral health clinician office visits (i.e., to physicians and non-physicians combined) than patients went out-of-network for all medical/surgical clinician office visits,” the report says of the nationwide outlook.

The report continues:

“Patients went out-of-network 6.9 times more often for psychiatrist office visits (15.3% as compared to 2.2%) and 8.2 times more often for psychologist office visits (18.2% as compared to 2.2%) than for primary care physician office visits.”

The trends even continued for telehealth services, as patients went out-of-network 4.7 times more often for telehealth visits with behavioral health clinicians compared telehealth services to medical and surgical clinicians.

The report says that the high percent of people finding behavioral health services purchased out-of-network means that there are not enough behavioral health professionals to participating in-network with insurance plans.

Behavioral health specialists tend to get reimbursed less for their office visits in network than compared to physician assistants, which can create “disincentives for behavioral health providers to participate in-network,” according to the report.

The report suggests that states should “expand their behavioral health networks,” and provide higher reimbursement rates for behavioral health specialists to incentivize behavioral health provider network participation.

Meanwhile, Maryland’s “out-of-network utilization disparities” could use improvement, the report finds. And the Mental Health Association of Maryland agrees.

“Data from this study shows Maryland among the lowest states in the nation with respect to several indicators used to determine overall access to mental health and substance use care,” according to a Wednesday news release from the mental health advocacy nonprofit.

Nationwide, patients are 8.9 times more likely to visit a psychiatrist out-of-network compared to medical or surgical specialist physicians. But Marylanders are 21.1 times more likely to visit a psychiatrist out-of-network compared to medical or surgical specialist physicians, the fourth highest rate in the nation after Kentucky, Rhode Island and Massachusetts.

It’s worse for psychologists, where Marylanders are 36.4 times more likely to use a psychologist out-of-network compared to medical and surgical specialist physicians. That’s higher than the national average of 10.6 times more likely to use a psychologist out-of-network, and is the second worse disparity following behind Massachusetts.

In response to the report, the Mental Health Association of Maryland added that in-network behavioral health professionals are reimbursed 23% less than other doctors performing comparable services in Maryland.

But there have been efforts from the Maryland General Assembly and the Moore administration to improve access to behavioral care across the state.

“The Maryland Insurance Administration (MIA) in recent years has  been one of the most vigorous regulatory bodies in the country in their enforcement of state and federal parity laws,” Linda Raines, chief executive officer of the Mental Health Association of Maryland, said in a written statement. “MIA is already implementing several of the recommendations from this report, and new legislation passed this year by the Maryland General Assembly will further enhance the agency’s enforcement authority.”

In the 2024 session, the legislature passed measures to improve the parity between behavioral health and traditional medical services.

Senate Bill 684, sponsored by Sen. Malcolm Augustine (D-Prince George’s) increased reporting requirements from insurance carriers on their coverage for behavioral health services, and makes it easier for the state Insurance Commissioner  to issue financial penalties if carriers do not comply with reporting requirements.

The bill also places the “burden of persuasions” onto insurance companies to prove that they are compliant with federal parity laws.

SB 684 was unanimously approved by the House of Delegates and the Senate, and is awaiting consideration from Gov. Wes Moore (D).

House Bill 1074, the House’s cross-file of the bill, was also unanimously approved by both chambers and is off to the governor’s desk. Del. Heather Bagnall (D-Anne Arundel) was the lead sponsor on the bill and it was co-sponsored by Democrats and Republicans.


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Report: Patients less likely to get behavioral health covered by insurance than other needs