Behavioral Health Benefits In Employer- Sponsored Health Plans, 1997

Transcription

1 E M P L O Y E R B E N E F I T S Behavioral Health Benefits In Employer- Sponsored Health Plans, 1997 Most employer plans cover behavioral health care, but the restrictions on such care can be fairly severe. by Jeffrey A. Buck, Judith L. Teich, Beth Umland, and Mitchell Stein PROLOGUE: Concerns over disparities in the level of insurance coverage for mental health and substance abuse (MH/SA) treatment compared with general medical coverage were partly responsible for the Mental Health Parity Act of 1996, which took effect last year. In addition, fourteen states have passed legislation that goes beyond the requirements of the federal parity act. To track behavioral health care benefits in employersponsored insurance, researchers from the Substance Abuse and Mental Health Services Administration (SAMHSA) worked with employer survey experts from William Mercer to analyze questions on MH/SA benefits from the Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans. This paper represents the second publication of survey results in Health Affairs; the first round appeared in July/August The authors found some improvement in benefits between 1996 and However, it is too early to tell if this improvement represents a permanent reversal in general terms. Jeffrey Buck, a clinical psychologist, is director of the Office of Managed Care in SAMHSA s Center for Mental Health Services (CMHS). Judith Teich is a policy analyst in the CMHS Office of Managed Care. Beth Umland is director of marketing and communications for William A. Mercer, Inc., and manages the annual Mercer/Foster Higgins health plans survey. Mitchell Stein is manager of employer surveys at Mercer. MH/SA 67 COVERAGE H E A L T H A F F A I R S ~ M a r c h / A p r i l The People-to-PeopleHealth Foundation, Inc.

2 M e n t a l H e a l t h / S u b s t a n c e A b u s e C o v e r a g e ABSTRACT: Data for 1997 show that three-quarters or more of employersponsored health plans continue to place greater restrictions on behavioral health coverage than on general medical coverage. The nature of these restrictions varies by plan type. Some improvement in the treatment of mental health/substance abuse (MH/SA) benefits in employer plans may be occurring, however. Comparisons with data from 1996 show that the proportion of plans with benefits for alternative types of MH/SA services, such as nonhospital residential care, has increased. Further, the proportion with special limitations on these benefits shows a modest decrease. 68 EMPLOYER BENEFITS Th ere i s a c onsi d erable ga p in coverage between physical and behavioral illnesses, and it is getting wider. One study, based on data from the Bureau of Labor Statistics (BLS) and other sources, found that the proportion of employees with coverage for mental health care increased from 1991 to However, more employees have multiple limits on their benefits, in part because of the increased use of managed care. Another study found that while health care costs per employee grew from 1989 to 1995, behavioral health care costs decreased, both absolutely and as a share of employers total medical plan costs. 2 A report by the Hay Group provides more recent evidence for these trends. 3 The percentage of plans with day limits on inpatient psychiatric care went from 38 percent in 1988 to 57 percent in For outpatient visit limits, the respective percentages were 26 percent and 48 percent. Based on this and other information about changes in psychiatric benefit limits, the Hay Group estimated that behavioral health care benefits decreased from 6.1 percent in 1988 to 3.1 percent in 1997 as a proportion of total benefit costs. The Hay Group study provides useful and recent data about coverage for behavioral health care. However, it is limited in that it is based on a convenience sample and covers only medium-size and large employers. Further, it presents information only on certain types of benefit limits and the levels of such limits. Information about services coverage, about differences by type of plan, or specific to substance abuse treatment is not reported. This paper provides new information, by reporting health plan data from a nationally representative sample of employers, including small employers, in 1996 and These findings provide information about mental health and substance abuse (MH/SA) services coverage, limits on MH/SA benefits, and differences by plan type and employer insurance status. n Study methods. Data are from the Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans. This survey collects information on a wide range of health care issues concerning employer health plans, including costs, strategic planning, and H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 2

3 E M P L O Y E R B E N E F I T S scope and limitations of health coverage. In 1996 additional questions on MH/SA benefits were added to the survey. The survey instrument was mailed to a stratified random sample of all U.S. employers with ten or more employees, including state and local governments. For private firms in the survey, a random sample was drawn from the Dun and Bradstreet database. All state governments were included; a random sample of county and local governments was drawn from the Census of Governments. The 1996 database included responses from 2,273 employers; the 1997 database included 3,156 respondents. Each respondent was requested to be the person who knows the most about the health care benefits program. Approximately half of the respondents provided data via telephone interviews, and many of the mail respondents also were contacted by phone to clarify inconsistent or incomplete data. The response rate for the 1997 survey was percent. The survey includes only employers who sponsor insurance. For each plan type that they sponsored, respondents were asked to provide information about the plan with the largest enrollment. Additionally, some analyses examined the single plan with the largest enrollment, regardless of type (the most prevalent plan ). Plan types were indemnity plans, preferred provider organizations (PPOs), point-of-service (POS) plans, health maintenance organizations (HMOs), and carve-out plans for MH/SA services. 4 Thus, a single employer could provide information on one plan or as many as five plans, if at least one of each type was offered. When in-network benefits differ from benefits outside of the network, information is provided about the in-network benefits. This way, we show the most generous benefits to which a participant has access. Study Findings Most employers provide at least some level of coverage for MH/SA care. However, a small minority of small employers (10 9 employees) and a handful of larger employers (0 or more) do not. In 1997, 9 percent of small firms and 1 percent of large firms did not offer MH/SA benefits to their employees in their most prevalent medical plan. Among all employers, 13 percent of indemnity plans and 12 percent of HMOs did not provide MH/SA coverage, while only 3 percent of POS plans and 7 percent of PPOs did not do so. Data on MH/SA costs were reported in the Mercer survey by only a small number of respondents, because this information is difficult to derive, and most plans do not report it to employers. For employers that did provide this information, the median amount spent on MH/SA services across all plan types in 1997 was 5 percent of total plan costs. This amount appears to be slightly higher for small em- MH/SA 69 COVERAGE H E A L T H A F F A I R S ~ M a r c h / A p r i l

4 M e n t a l H e a l t h / S u b s t a n c e A b u s e C o v e r a g e 70 EMPLOYER BENEFITS ployers (10 9 employees) and slightly lower for large firms. n Covered services. Even among plans providing MH/SA benefits, there was considerable variation by type of plan as to the specific services that were covered (Exhibit 1). For example, although 96 percent of PPO plans covered inpatient psychiatric care, only 88 percent of HMOs did so. Coverage for outpatient therapy was also slightly lower among HMOs than among indemnity and POS plans. Indemnity plans were the least likely to offer crisis-related services, whereas most carve-out plans did. Approximately half of all plans covered nonhospital residential services, while about two-thirds of plans covered intensive nonresidential services. Similarly, there was wide variation in coverage for substance abuse services. Most plans were likely to cover inpatient detoxification and outpatient counseling, and approximately three-quarters of plans covered outpatient detoxification. 5 About half of plans provided coverage for nonhospital residential and intensive nonresidential services, as well as case management/referral. Coverage for methadone maintenance was least likely to be offered by plans. n Benefit limits. MH/SA benefits often are restricted through provisions that place more limits on their use or impose greater cost sharing than for other health services. In a majority of plans these restrictions are the same for MH/SA services. Accordingly, the infor- EXHIBIT 1 Percentage Of Plans Covering Specific Mental Health And Substance Abuse (MH/SA) Services, By Type Of Plan, 1997 Covered service Most prevalent plan a Indemnity PPO POS HMO Carve-out Mental health N = 2,583 N = 768 N = 1,514 N = 795 N = 1,209 N = 192 Inpatient psychiatric care Nonhospital residential Intensive nonresidential Outpatient therapy Crisis-related services 94% % Substance abuse N = 2,371 N = 7 N = 1,392 N = 748 N = 1,112 N = 4 Inpatient detoxification Outpatient detoxification Nonhospital residential Intensive nonresidential Outpatient counseling Case management/referral Methadone maintenance SOURCE: Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans (1997). NOTES: PPO is preferred provider organization. POS is point-of-service plan. HMO is health maintenance organization. Includes all employers with ten or more employees. Excludes plans that report that they do not offer MH/SA benefits. a Plan with the largest enrollment, regardless of type. 96% % % % H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 2

5 E M P L O Y E R B E N E F I T S mation that follows describes limits for mental health services only. A quarter or less of plans within each plan type reported having no special limits on inpatient mental health benefits (Exhibit 2). Generally, carve-out plans and HMOs were the least likely to have special limits, and indemnity plans were the most likely. Among the most prevalent plans that had special coverage limits, an annual limit on inpatient days was the most common limitation. Annual or lifetime limits were used somewhat less. Higher cost sharing was used by the smallest percentage, and the use of separate deductibles was almost nonexistent. For outpatient mental health services, a quarter of the most prevalent plans had no special limits. There was little variation from this percentage by plan type, with the exception of carve-out plans, of which a third had no special limits. Unlike the situation for inpatient services, there did not seem to be any marked preference for the use of any type of limitation for outpatient services. For both inpatient and outpatient benefits, there appear to be preferences in the use of special limitations within specific plan types. Indemnity and PPO plans used annual and lifetime maximums and day limits for inpatient benefits. For outpatient benefits, they preferred annual spending limits. HMOs and carve-out plans emphasized the use of day limits for inpatient services and visit MH/SA 71 COVERAGE EXHIBIT 2 Percentage Of Plans With Limits On Mental Health Benefits, By Type Of Plan, 1997 Most prevalent plan Indemnity PPO POS HMO Carve-out Inpatient limits N = 2,367 N = 721 N = 1,421 N = 740 N = 1,0 N = 3 No special limits Amount payable per year Amount payable per lifetime Number of days per year Higher coinsurance Separate deductible 21% % Outpatient limits N = 2,314 N = 705 N = 1,3 N = 7 N = 1,079 N = 3 No special limits Amount payable per year Amount payable per lifetime Number of visits per year Higher coinsurance SOURCE: Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans (1997). NOTES: PPO is preferred provider organization. POS is point-of-service plan. HMO is health maintenance organization. Includes all employers with ten or more employees. Excludes plans that report that they do not offer MH/SA benefits. Percentages are for plans reporting special limits on inpatient and outpatient benefits. a Question is not applicable and was not asked of these respondents. 20% % % % a a a H E A L T H A F F A I R S ~ M a r c h / A p r i l

6 M e n t a l H e a l t h / S u b s t a n c e A b u s e C o v e r a g e 72 EMPLOYER BENEFITS limits for outpatient services. Use of particular limits within POS plans generally fell between that of the others, perhaps because this type of plan shares some features of each. Median values for the most prevalent plans show that mental health benefits are significantly restricted when special limits are used (Exhibit 3). Maximum lifetime limits for both inpatient and outpatient care were only. Annual limits were only $5,000 for inpatient care and $2,000 for outpatient care. Day limits remained at the traditional limit of thirty inpatient days; however, the median limit on outpatient visits, traditionally twenty, reached twenty-five in Plan types varied some in these amounts. HMOs and carve-out plans had higher median amounts for lifetime maximums, but these plans rarely used such maximums. Median inpatient day limits, which were used relatively frequently by such plans, were the same as for other types of plans. However, the median for outpatient visit limits was lower for HMOs than for any other plan type. n Differences by type of funding. Rather than contracting with health insurers, many employers particularly large firms have implemented self-funded plans, which pay physicians and hospitals directly. The provisions of the Employee Retirement Income Security Act (ERISA) of 1974 exempt most self-funded plans from state mandates that require parity in coverage for MH/SA services and other health care. For this reason, we chose to examine differences between insured and self-funded plans in their treatment of MH/SA benefits. Insured plans include conventionally insured (nonexperience-rated), experience-rated (no minimum premium de- EXHIBIT 3 Scope Of Limits On Mental Health Benefits, By Type Of Plan, 1997 Inpatient limits Amount payable per year Amount payable per lifetime Number of days per year Outpatient limits Amount payable per year Amount payable per lifetime Number of visits per year Most prevalent plan Indemnity PPO POS HMO Carve-out $5,000 $2,000 $5,000 $2,000 $, $5,000 $2,000 $5,000 $1,800 $5,000 $40,000 $1,0 $20, a $,000 a SOURCE: Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans (1997). NOTES: PPO is preferred provider organization. POS is point-of-service plan. HMO is health maintenance organization. Includes all employers with ten or more employees. Excludes plans that report that they do not offer MH/SA benefits. Excludes plans that reported offering benefits but did not provide data on specific limits. All values are expressed as median amounts, in dollars or days/visits per year. a Data were not reported due to the small number of plans. Other cells provide data from at least sixty plans. H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 2

7 E M P L O Y E R B E N E F I T S vice), and minimum premium (or split-funded ) plans; self-funded plans include those with and without stop-loss protection. Survey responses for 1997 indicated that 85 percent of the most prevalent plans were not self-funded. Any given employer may sponsor both insured and self-funded plans. Although some firms with under 200 employees had self-funded plans, the majority of self-funded plans were sponsored by larger firms (0 or more employees). The larger the number of employees, the greater the likelihood that the firm has a self-funded plan. In 1997, 10 percent of insured plans and 8 percent of self-funded plans did not offer coverage for MH/SA services. Almost all plans offered coverage for inpatient psychiatric care, and a high proportion covered outpatient therapy (Exhibit 4). Among plans offering coverage for substance abuse, most plans of both types covered inpatient detoxification. Three-quarters or more of both types covered outpatient detoxification and counseling. With the exception of coverage for crisis-related mental health services, an equal or greater percentage of self-funded plans covered each category of service. The greatest differences appear to be for less traditional types of services. For mental health, these generally are services that are more intensive than outpatient therapy but less intensive than traditional inpatient care. For substance abuse, these MH/SA 73 COVERAGE EXHIBIT 4 Percentage Of Plans Covering Specific Mental Health And Substance Abuse (MH/SA) Services, By Insured/Self-Funded Status, 1997 Covered service Insured (most prevalent plan) a Mental health N = 1,459 N = 961 Inpatient psychiatric care b Nonhospital residential Intensive nonresidential Outpatient therapy Crisis-related services b 94% Self-funded (most prevalent plan) 95% Substance abuse N = 1,3 N = 911 Inpatient detoxification Outpatient detoxification Nonhospital residential b Intensive nonresidential Outpatient counseling Case management/referral b Methadone maintenance SOURCE: Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans (1997). NOTES: Includes all employers with ten or more employees. Percentages exclude those plans that do not provide coverage for MH/SA services. a Data represent the plan with the highest enrollment, regardless of plan type, for each employer. b Difference is not significant (p <.05) H E A L T H A F F A I R S ~ M a r c h / A p r i l

8 M e n t a l H e a l t h / S u b s t a n c e A b u s e C o v e r a g e 74 EMPLOYER BENEFITS are services that substitute for inpatient or residential care. Twenty-three percent of both insured and self-funded plans reported having no special limits on inpatient mental health coverage (Exhibit 5). However, a higher proportion of insured plans had no special limits on outpatient services compared with self-funded plans. Self-funded plans with limits more commonly used maximum limits for both annual and lifetime expenditures. Insured plans were more likely to limit inpatient days and outpatient visits. n Changes since Questions relating to MH/SA benefits in the 1997 Mercer/Foster Higgins survey were the same as in 1996, enabling observations on changes over time. For those plans that reported coverage of specific MH/SA services, the proportion covering any particular mental health service changed little or increased somewhat in 1997 (Exhibit 6). For mental health benefits, coverage rates for traditional inpatient psychiatric treatment and outpatient therapy were largely unchanged. However, coverage for alternative care nonhospital residential, intensive nonresidential, and crisisrelated services increased by five percentage points or more. For substance abuse, detoxification services and methadone maintenance services were largely unchanged since Other services increased by five or more percentage points. This was particularly true for nonhospital residential care, which increased by more than a third. With one exception, the use of special limits for mental health benefits declined from 1996 to 1997 (Exhibit 7). For both inpatient and outpatient benefits, the proportion of plans with no special limits increased. For those using such limits, there was a decrease in EXHIBIT 5 Percentage Of Plans With Limits On Mental Health Benefits, By Insured/ Self-Funded Status, 1997 Type of limit No special limits Amount payable per year Amount payable per lifetime Number of days per year Higher coinsurance Separate deductible Inpatient limits Insured (most prevalent plan) a N = 1,5 23% b b 1 b Self-funded (most prevalent plan) N = % b b 0 b Outpatient limits Insured (most prevalent plan) a N = 1,276 27% b c Self-funded (most prevalent plan) N = 909 SOURCE: Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans (1997). NOTES: Includes all employers with ten or more employees. Percentages exclude plans that reported having no special limits. a Data represent the plan with the highest enrollment, regardless of plan type, for each employer. b Difference is not significant (p <.05). c Not applicable. % b c H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 2

9 E M P L O Y E R B E N E F I T S EXHIBIT 6 Percentage Of Plans Covering Specific Mental Health And Substance Abuse (MH/SA) Services, In Most Prevalent Plan, 1996 And 1997 Covered service 1996 a 1997 Mental health N = 1,1 N = 2,583 Inpatient psychiatric care Nonhospital residential Intensive nonresidential Outpatient therapy Crisis-related services 91% % Substance abuse N = 1,777 N = 2,371 Inpatient detoxification Outpatient detoxification Nonhospital residential Intensive nonresidential Outpatient counseling Case management/referral Methadone maintenance SOURCE: Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans (1996, 1997). NOTES: Includes all employers with ten or more employees. Percentages exclude those plans that do not provide coverage for MH/SA services. a Data represent the plan with the highest enrollment, regardless of plan type, for each employer. b Difference is not significant (p <.05) the percentage of plans with special day or visit limits. Although the use of maximum dollar limits for inpatient care slightly increased, the use of other types of limits was essentially unchanged. Discussion n Comparison with previous studies. Previous studies have documented the differences in health insurance coverage between physical and behavioral health care. Generally, they also have shown that MH/SA 75 COVERAGE EXHIBIT 7 Percentage Of Plans With Limits On Mental Health Benefits, 1996 And 1997 Type of limit No special limits Amount payable per year Amount payable per lifetime Number of days/visits per year Higher coinsurance Separate deductible Inpatient limits 1996 (most prevalent plan) a N = 1,761 16% 21 b b 2 b 1997 (most prevalent plan) N = 2,367 21% 26 b b 1 b Outpatient limits 1996 (most prevalent plan) a N = 1,7 15% 28 b 19 b 33 c 1997 (most prevalent plan) N = 2,314 SOURCE: Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans (1996, 1997). NOTE: Includes all employers with ten or more employees. Percentages exclude those plans that do no provide coverage for MH/SA services. Percentages for specific limitations exclude plans that reported having no special limits on MH/SA coverage. a Data represent the plan with the highest enrollment, regardless of plan type, for each employer. b Difference is not significant (p <.05). c Not applicable. 25% 29 b b 21 c H E A L T H A F F A I R S ~ M a r c h / A p r i l

10 M e n t a l H e a l t h / S u b s t a n c e A b u s e C o v e r a g e HMO limits on outpatient mental health/substance abuse services are the least generous in every category. 76 EMPLOYER BENEFITS these differences have been growing in recent years, with MH/SA benefits increasingly subject to special limitations. The findings we have reported here are not directly comparable with those from previous studies, for several reasons. First, our findings are derived from a stratified random sample of employers with ten or more employees. Others rely upon convenience samples or samples that exclude smaller employers. Second, our study reports data for 1997, whereas nearly all others are for earlier years. Finally, we report results by percentage of plans, while some others report by percentage of employees. Despite these differences, we find (as others do) that most employer-sponsored plans cover MH/SA services. Traditional services, such as inpatient psychiatric care, are still the most commonly covered. But half or more of employers most prevalent plans also covered less traditional services such as nonhospital residential care. Three-quarters or more of employer-sponsored health plans continued to place greater restrictions on behavioral health coverage than on general medical coverage. These restrictions can be fairly severe. Special limits on inpatient days and outpatient visits did not vary much from the customary level of thirty days and twenty visits. For plans with annual maximums, median dollar limits were $5,000 for inpatient services and $2,000 for outpatient care. n Restrictions and plan types. The nature of these restrictions varies by plan type. Generally, indemnity and PPO plans emphasize annual and lifetime spending limits, while HMOs and carve-out plans emphasize day and visit limits. Median HMO limits on outpatient services are the least generous in every category. Differences in the use of limits by plan type may reflect administrative convenience as well as benefit generosity. Indemnity plans and PPOs generally exercise less utilization management than HMOs or carve-out plans do. Annual spending limits then may provide more certainty about risk compared with use of day/visit limits, which may be subject to variable provider rates. In contrast, where HMOs or carve-out plans subcapitate service provision or operate under a staff model, day/visit limits may be the simplest method of limiting benefits. Median levels for annual maximums suggest that indemnity and PPO plans using such limits are less generous than are HMOs and carve-out plans with day and visit limits. For example, the median H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 2

11 E M P L O Y E R B E N E F I T S level of $5,000 for inpatient psychiatric care clearly allows for fewer hospital days than a thirty-day limit. For outpatient services, only carve-out plans seem clearly more generous than other types. However, we do not know to what extent utilization management practices in HMOs and carve-out plans may affect these differences. n Changes in benefits and plan types. Clear differences by plan type in the characteristics of MH/SA benefits and limits provide one explanation for changes in MH/SA coverage documented by this and previous studies. From 1993 to 1997 enrollment in traditional indemnity plans for employees with health coverage plunged from 48 percent to just 15 percent. In contrast, enrollment in PPOs grew from 27 percent to 35 percent, closed-panel HMOs from 19 percent to percent, and POS plans from 7 percent to 20 percent. Thus, this study and previous ones that show changes in overall MH/SA benefits partly are reflecting changes in enrollment patterns and not necessarily explicit decisions by employers about such benefits. Additional years of data from the Mercer/Foster Higgins survey should allow us to examine this issue more closely. n Parity laws. Federal and state parity laws seek to provide equivalence in insurance coverage between general health care and behavioral health care. At the federal level, the Mental Health Parity Act of 1996 (P.L ) requires that, beginning in 1998, insurers provide the same annual and lifetime spending limits for mental health benefits as they do for other health care benefits. These provisions apply to all health plans offered by employers with more than fifty employees, provided that they offer mental health benefits in such plans. Our data show that indemnity and PPO plans will be more heavily affected by this mandate than HMOs or carve-out plans will be. Also, plans with such limits appear to be less generous than those with other types. Therefore, it seems likely that they will impose other limits permitted by law to accommodate its provisions. State parity laws also affect MH/SA benefit provision. As of December 1998 fourteen states had enacted parity laws that go beyond the requirements of the federal parity act. 6 Yet with ERISA provisions, most self-funded plans are exempt from state parity mandates. This may partly explain some of the observed differences between insured and self-funded plans. Although both types are equally likely to have special limits on inpatient mental health care, insured plans are less likely to impose special restrictions on outpatient services. These differences are minor, however. Unlike state laws, the federal parity law applies to all types of plans for employers with more than fifty employees. This, and the law s application to annual and lifetime spending limits, could mean that limits used by insured and self-funded plans could become less, MH/SA 77 COVERAGE H E A L T H A F F A I R S ~ M a r c h / A p r i l

12 M e n t a l H e a l t h / S u b s t a n c e A b u s e C o v e r a g e rather than more, alike. First, because self-funded plans are more likely to be offered by large employers, the size exemption probably will apply more to insured plans. Second, a greater percentage of self-funded plans use the types of benefit limits that are addressed by the federal mandate. As a result, the use of special annual and lifetime maximums for self-funded plans could drop significantly, while insured plans could be relatively unaffected. Government mandates may work to expand the characteristics of employer-sponsored MH/SA benefits. Nevertheless, some improvement in the treatment of MH/SA benefits in employer plans may be occurring independent of such mandates. Previous studies generally have shown that special limits on MH/SA benefits have been increasing and that the proportion of health plan dollars for these services have been decreasing. However, our data show a reversal in this general trend for Generally, the proportion of plans covering nontraditional MH/SA services has increased. In addition, the use of special limits for mental health benefits has declined. Additional years of data are needed, though, to determine if this represents a permanent reversal. 78 EMPLOYER BENEFITS The views expressed in this paper are solely those of the authors and do not necessarily represent those of their respective organizations. NOTES 1. G.A. Jensen et al., Mental Health Insurance in the 1990s: Are Employers Offering Less to More? Health Affairs (May/June 1998): J.A. Buck and B. Umland, Covering Mental Health and Substance Abuse Services, Health Affairs ( July/August 1997): Health Care Plan Design and Cost Trends 1988 through 1997 (Washington: Hay Group, May 1998). 4. Carve-out plans refer only to situations in which the employer directly contracted with a managed behavioral health care company and asked one or more of its medical plans to exclude coverage for MH/SA care. In 1997 carveout plans were used by only 2 percent of all employers, while percent of employers with 20,000 or more employees have carved MH/SA benefits out of one or more plans. Carve-out plans are distinct from carve-ins, where the health plan (such as an HMO) has subcontracted with a managed behavioral health care company to deliver the MH/SA benefits. Carve-in arrangements are included within the other plan types examined in this paper. 5. In addition to detoxification, rehabilitation is another inpatient substance abuse benefit that some plans cover. This benefit will be addressed in future surveys. 6. M.L. Rosenbach and C. Young, Evaluation Design for the Vermont Parity Act, Final Report (Rockville, Md.: Substance Abuse and Mental Health Services Administration, December 1998). H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 2