Dominic Hodgkin, PhD¹, Constance M. Horgan, ScD², Deborah W. Garnick, PhD², and Elizabeth L. Merrick, PhD, MSW². (1) Schneider Institute for Health Policy, The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MS 035, Waltham, MA 02454, 781-736-8551, hodgkin@brandeis.edu, (2) Schneider Institute for Health Policy, Heller Graduate School, Brandeis University, 415 South Street, MS 035, Waltham, MA 02454

An important dimension of access to behavioral health care is how treatment is covered in private health insurance benefits. Debate continues as to whether any new federal parity law should require parity with medical care not only in benefit limits but also in cost-sharing, which affects many more patients. The spread of managed care does not appear to have resulted in lower copayments and coinsurance, despite expectations in some quarters that availability of other tools (utilization controls) would make cost-sharing less necessary. Many plans are reportedly increasing consumer cost-sharing for other types of care (hospital use, pharmaceuticals) in response to consumer backlash against administrative controls. There is debate over whether similar changes may be occurring for behavioral health. This national survey on alcohol, drug abuse and mental health services collected data for 2003 from over 400 health plans in 60 market areas, resulting in national estimates of benefits provisions. In this paper, we report 2003 findings on which services are covered, and with what cost-sharing requirements. We also compare selected findings to the 1999 round of the survey (response rate=92%), that found 40% of plans required copayments of $20 or more for outpatient care, and another 15% required 50% coinsurance. We examine whether the level of cost-sharing has changed since 1999, in light of subsequent changes in both the legislative and industry environment. The results are important to interpreting what has been happening to consumer access, and what types of policy change would be most likely to improve benefits.

Learning Objectives: At the conclusion of the session, participants will be able to

• Describe typical covered services and cost-sharing requirements in commercial managed care products.
• Summarize changes in cost-sharing requirements since 1999.
• Describe differences in cost sharing based on product type and contracting arrangements.

Keywords: Contracting, Managed Care

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.