Benefit Limits for Behavioral Health Care in Private Health Plans

Abstract

Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans’ access to new managed care tools has not led them to stop using benefit limits for cost containment purposes.

Appendix

The study was linked to the Community Tracking Study (CTS), a longitudinal study of health system change funded by the Robert Wood Johnson Foundation (Kemper et al. 1996). At the first stage, the primary sampling units were the 60 market areas the CTS had selected to be nationally representative. The CTS study defined market areas based on Metropolitan Statistical Areas (for metropolitan communities) or Bureau of Economic Analysis Economic Areas (for non-metropolitan communities). The second stage of our sampling consisted of selecting plans within market areas. Plans serving multiple markets were defined as separate plans for the study and data were collected with reference to the specific market.

The 1999 sample frame was based on a CTS household survey that used responses to identify and survey insurers and health plans regarding plan characteristics. This survey yielded around 1000 entities categorized as health plans. After excluding entities that were exclusively indemnity plans and those no longer present within market areas, 944 plans constituted our sample frame, from which 720 market-specific plans were selected with equal probability and without replacement across the sites. The plan sample was allocated to each market area based on the weighted estimate of plan enrollees in each site, with proportional distribution between preferred-provider organization (PPO)-only and health maintenance organization (HMO)/multitype plans. Of the 720 sampled plans, 247 were deemed ineligible because they had closed, merged or were otherwise unreachable, had fewer than 300 subscribers in the market, did not offer comprehensive health care products, or served only Medicaid/Medicare. This left 473 eligible plans, of which 434 (92%) responded, regarding 787 eligible insurance products.

For the 2003 survey, we augmented the 1999 sample of 720 plans with a national sample of plans not previously operating in the market areas. Of the 110 new plans identified, we selected 94, maintaining the same sampling rates as those in 1999. Thus, the 2003 sample frame consisted of 1054 plans, and the sample totaled 814 plans including all 1999 eligible sampled cases plus a sample of 1999 ineligibles and new plans. Of these 814 plans, 373 were ineligible, leaving 441 eligible plans, of which 368 (83%) responded and reported on 812 products. Four products that were “consumer driven” (a new category in 2003), were excluded from analyses. Data used in this study were from the 2003 survey.