What GAO Found
Based on stakeholders interviewed and research reviewed, GAO found that consumers with coverage for mental health care experience challenges finding in-network providers. For example, in-network providers may not be accepting new patients or there may be long wait times to see them. Such challenges could cause consumers to face higher health care costs, delays in receiving care, or difficulties in finding a provider close to home. Factors contributing to these challenges included low reimbursement rates for mental health services and inaccurate or out-of-date information on provider networks, according to stakeholders and research GAO reviewed.
GAO also found that consumers experience challenges with restrictive health plan approval processes and plan coverage limitations, which can limit their ability to access services. Many of the 29 stakeholder organizations interviewed and reports GAO reviewed noted that the process for getting approval for coverage for mental health services can be more restrictive than it is for medical services. For example, representatives from one health system reported that some health plans are less likely to grant prior authorization for mental health hospital stays compared with medical and surgical hospital stays. Stakeholders also noted various coverage restrictions that limit consumers’ access to certain mental health treatments or that limit the types of providers eligible for payment. These include certain statutory restrictions on coverage of inpatient care in certain settings under Medicaid and the types of mental health providers not eligible for reimbursement under Medicare.
Federal efforts may address aspects of the challenges experienced by consumers attempting to access care.
Access to in-network providers: The Department of Labor (DOL) and the Department of Health and Human Services’ (HHS) Centers for Medicare & Medicaid Services are taking steps to ensure access to in-network mental health providers by, for example, enforcing requirements for certain health plans to update and maintain provider directories.
Workforce shortages: The Health Resources and Services Administration within HHS manages several programs that provide funding intended to increase the mental health workforce.
System capacity: The Substance Abuse and Mental Health Services Administration within HHS manages several programs aimed at addressing structural issues that contribute to a lack of capacity in the mental health system, including grant programs to increase access to community-based mental health care.
Enhanced oversight: DOL and HHS are taking steps to enhance their oversight of the use of non-quantitative treatment limitations by health plans, such as prior authorization requirements, as part of their broader responsibilities to oversee compliance with mental health parity laws. These laws require that coverage of mental health treatment be no more restrictive than coverage for medical or surgical treatment. In addition, DOL has asked Congress to further expand its oversight authorities.
Why GAO Did This Study
Mental health conditions affect a substantial number of adults in the U.S. In 2020, an estimated 53 million adults in the U.S. (21 percent) had any mental illness and 14 million adults (5.6 percent) had serious mental illness. Despite the need for services to treat mental health conditions, there have been longstanding concerns in the U. S. about the availability of these services. Additionally, although many consumers have coverage for mental health services through their public or private health plans, having such coverage does not guarantee access.
This report describes (1) the challenges consumers with coverage for mental health care services experience with accessing those services and (2) ongoing and planned federal efforts to address these challenges.
To conduct this work, GAO interviewed federal officials and representatives from 29 stakeholder organizations representing consumers, health plans, providers, insurance regulators, and mental health and Medicaid agencies. These included national organizations and organizations from four states—Connecticut, Oregon, South Carolina, and Wisconsin—selected based on mental health metrics and geographic variation, among other factors. GAO also reviewed relevant reports obtained from these agencies and organizations and reviewed academic and industry research focused on consumer access to mental health care.
DOL and HHS provided technical comments, which GAO incorporated as appropriate.
For more information, contact John E. Dicken at (202) 512-7114 or [email protected]