Mental Health and Substance Use: State and Federal Oversight of Compliance with Parity Requirements Varies

MHPAEA requires large group health plans that offer MH/SU benefits to ensure parity between MH/SU and medical/surgical benefits. To meet the essential health benefits requirements of the Patient Protection and Affordable Care Act, certain issuers offering small group and individual plans must comply with MHPAEA's MH/SU parity requirements.

The 21st Century Cures Act included a provision for GAO to review federal and state oversight of MH/SU parity requirements and the extent to which health plans comply with these requirements. This report, among other objectives, (1) examines how DOL, HHS, and states oversee health plan compliance with MH/SU parity requirements; and (2) describes what is known about the extent to which health plans are complying with MH/SU parity requirements.

For this report, GAO reviewed DOL and HHS policies, guidance, and reports; conducted a survey and received responses from all 50 states and the District of Columbia about oversight practices; interviewed officials from DOL, HHS, and selected states; interviewed national and state stakeholders; and reviewed available research studies regarding health plan compliance with MH/SU parity.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) generally requires that coverage for mental health and substance use disorder (MH/SU) be no more restrictive than coverage for medical/surgical services. State agencies and the Departments of Labor (DOL) and Health and Human Services (HHS) share responsibility for overseeing compliance with these MH/SU parity requirements among group and individual health plans. These oversight practices vary.

While nearly all of the state officials who responded to GAO's survey reported that they perform some review of group and individual insurance plans for compliance with MH/SU parity requirements before they are approved to be sold to consumers, states vary in the frequency and type of reviews they conduct after consumers enroll in plans. For example, officials from 12 states reported that they conducted a targeted review of specific MH/SU parity concerns in 2017 and 2018, with the number of reviews ranging from one to 22 reviews per state.

DOL and HHS conduct targeted reviews of certain employer-sponsored group plans when they receive information—such as consumer complaints—about possible noncompliance with MH/SU parity requirements or other federal heatlh care requirements. Unlike states, these reviews only occur after consumers enroll in these plans. For example, in fiscal years 2017 and 2018, DOL completed 302 reviews that included a review of MH/SU parity compliance in its oversight of 2.2 million plans. Nearly all these reviews originated from complaints or other information about potential noncompliance with federal health care laws unrelated to MH/SU parity.

According to DOL and HHS officials, the departments have not analyzed whether relying on targeted reviews alone increases the risk of noncompliance with MH/SU parity requirements in employer-sponsored group plans. Without such an evaluation, DOL and HHS do not know if their oversight is effective or whether they need to adopt additional strategies.

While states, DOL, HHS, and the research GAO reviewed identified some instances of noncompliance with MH/SU parity requirements, the extent of compliance with these requirements is unknown. States, DOL, and HHS have identified some noncompliance with MH/SU parity requirements based on consumer complaints and other information about potential noncompliance. For example, DOL reported citing 113 violations of MH/SU parity requirements through its reviews in 2017 and 2018. The available research studies GAO reviewed also identified noncompliance with some of the requirements by reviewing plan documentation and benefit data, among other methods. However, according to stakeholders GAO interviewed, complaints are not a reliable indicator of the extent of noncompliance because consumers may not know about MH/SU parity requirements or may have privacy concerns related to submitting a complaint.

GAO is recommending that DOL and HHS evaluate whether relying on targeted oversight is effective for ensuring compliance with MH/SU parity requirements or whether alternative approaches are needed. DOL and HHS concurred with GAO's recommendations.

As of 2018, approximately 19.1 percent of U.S. adults were diagnosed  with a mental illness and approximately 15.0 percent received mental  health services. Further, among individuals aged 12 and over, an  estimated 7.8 percent had a substance use disorder, with approximately  1.4 percent receiving substance use treatment. Congress has taken  steps to ensure that individuals seeking mental health and substance use  disorder (MH/SU) treatment do not face discrepancies in coverage. The  Paul Wellstone and Pete Domenici Mental Health Parity and Addiction  Equity Act of 2008 (MHPAEA) requires large group health plan sponsors,  including employers, that choose to offer MH/SU benefits to ensure that  coverage of MH/SU treatment is no more restrictive than coverage for  medical/surgical treatment. Generally, this means that the requirements  or limitations imposed on MH/SU benefits—such as copayment amounts,  number of annual visit allowed, or preauthorization of services—must be  in parity with those imposed on medical/surgical benefits. The Patient  Protection and Affordable Care Act (PPACA) extended these parity  requirements to most small group and individual health plans.

At the federal level, the Department of Health and Human Services  (HHS), the Department of Labor (DOL), and the Department of the  Treasury (Treasury) share joint responsibilities for overseeing compliance  with MHPAEA and have jointly developed related regulations and  guidance. Throughout this report, we will refer to MHPAEA  requirements—contained in both laws and regulations—as MH/SU parity  requirements. States are generally responsible for enforcing MH/SU  parity requirements through their oversight of health insurance companies  (known and hereafter referred to as issuers) that sell group and individual  health plans in their states.

In recent years, questions have been raised about disparities in coverage  and access to MH/SU services despite the MH/SU parity requirements  under MHPAEA. For example, a 2017 study from the consulting firm  Milliman found that consumers used an out-of-network provider for a  substantially higher proportion of MH/SU care than they did for  medical/surgical care. This could lead to higher out-of-pocket costs for  individuals using out-of-network MH/SU services. Similar issues have  also been identified by stakeholder coalitions, a presidential taskforce,  and consumer lawsuits.

The 21st Century Cures Act includes a provision for us to review certain  aspects of state and federal oversight of MH/SU parity requirements and  to describe the extent to which plans comply with these requirements.  This report  1.  examines how states and responsible federal agencies oversee group  and individual health plans for compliance with MH/SU parity  requirements;  2.  describes what is known about the extent to which these plans comply  with MH/SU parity requirements; and  3.  describes how responsible federal agencies coordinate their oversight  to support states.

In appendix I we also provide information on MH/SU parity requirements  in Medicaid and the State Children’s Health Insurance Program.

To examine how states oversee compliance with MH/SU parity  requirements, we administered a survey to all 50 states and the District of  Columbia (hereafter referred to as “states”). We asked states to report  information about how they review health insurance plans for compliance  with MH/SU parity requirements and to identify any related enforcement  activities in 2017 and 2018. We also asked about coordination between  the states and federal agencies. We conducted the survey from April  2019 to August 2019 and received responses from all states. For some  questions, a few states either did not respond or told us they had no basis  on which to respond. We did not independently verify the information  reported by the states in the survey, but reviewed responses and followed  up with state officials when reported information appeared inconsistent or  needed clarification. We interviewed an official and reviewed  documentation from the National Association of Insurance  Commissioners (NAIC) to provide additional national context to state  responses.

We also selected three states to illustrate aspects of, and variations in,  state oversight of MH/SU parity requirements. These states were selected  based on recommendations by stakeholders—both federal officials and  national advocacy groups—and to represent geographic diversity across  the United States. Using these criteria, we selected Maryland,  Massachusetts, and Washington. We interviewed officials responsible for  overseeing health insurance plans in each of these states and reviewed  documentation related to MH/SU parity oversight. We also interviewed  consumer advocacy groups in the selected states. We also spoke to  officials in Wyoming to obtain the perspective of one of the four states  where HHS, rather than the state insurance department, is enforcing  federal MH/SU parity requirements. To examine how relevant federal  agencies—HHS, DOL, and Treasury—oversee MH/SU parity compliance,  we reviewed relevant laws, regulations, and sub-regulatory guidance;  reviewed agency reports on enforcement activities; and interviewed  relevant officials. We compared HHS and DOL oversight activities and  related policies and procedures with the federal internal control standards  related to risk assessment.

To describe what is known about the extent to which plans comply with  MH/SU parity requirements, we interviewed officials from HHS and DOL  and reviewed the agencies’ reports on parity enforcement activities for  fiscal years 2017 and 2018. These were the most recent reports available  at the time of our review. For more information on the types of violations  of MH/SU parity requirements that federal agencies identified in these  reports, we reviewed the letters DOL sent issuers or plans identifying  noncompliance for cases closed in fiscal years 2017 and 2018. We used  information from our state survey on state identified noncompliance and  enforcement actions taken by the states in 2017 and 2018, and from  interviews and documentation from the three selected states, to provide  additional examples.

We interviewed representatives from several stakeholder groups,  including seven advocacy groups (focusing on substance use, mental  health, or both), four groups representing the insurance industry, one  group representing medical providers, and NAIC, to gain an  understanding of what is known about compliance with MH/SU parity  requirements both nationally and locally. We also performed a literature  review of studies that assessed MH/SU parity compliance. See appendix  II for a description of the methodology used and results of the literature  review. We also identified Mercer’s National Survey of Employer- Sponsored Health Plans as a source of information about employer- sponsored group plan health benefits, including information about  compliance with MH/SU parity compliance. We assessed the reliability of  the Mercer data through a review of the methodology for Mercer’s  employer surveys and a discussion with a Mercer official knowledgeable  of the survey methodology. We determined that the data were sufficiently  reliable for the purposes of our reporting objective.

To describe how responsible federal agencies (HHS, DOL, and Treasury)  coordinate their oversight to support states, we reviewed federal  regulations, guidance, documents, and websites. This included a review  of the HHS Action Plan and a review of proposed guidance. We  interviewed officials from HHS and DOL on the guidance they have  published or proposed and about their coordination with states. We  interviewed officials from Treasury about their oversight related to MH/SU  parity and coordination with HHS and DOL. We used information from our  51 state survey on coordination with federal agencies and use of federal  guidance for MH/SU parity enforcement. We also used information from  our interviews with officials from the three selected states and stakeholder  groups.

We conducted this performance audit from December 2018 to December  2019 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

The majority of Americans receive their health coverage through private  health insurance, either by purchasing health coverage directly or  receiving coverage through their employer. Many of those with private  coverage are enrolled in plans purchased from state-licensed or state- regulated issuers. Others are covered by plans where their employer sets  aside funds to pay for employee health care, known as self-funded plans.  In general, those who obtain private health coverage do so in one of three  market segments: individual, small group, or large group. Enrollees in the  individual market purchase private health insurance plans directly from a  state-regulated issuer—not in connection with a group health plan. In the  small group and large group markets, enrollees generally obtain health  insurance coverage through a group health plan offered through a plan  sponsor (typically an employer).

Health benefits commonly include plan design features that require  enrollees to pay for a portion of their health care, limit the amount or  number of treatments enrollees can receive, and limit the scope or  duration of treatments that enrollees may receive. Prior to the  implementation of the MHPAEA, health plans offered through employers  covering MH/SU often used plan design features that were more  restrictive or provided lower levels of coverage for MH/SU benefits than  for medical/surgical benefits. For example, prior to MHPAEA, an  employer’s plan could cover unlimited hospital days and outpatient office  visits and require 20 percent coinsurance for outpatient office visits for  medical/surgical treatment while, for MH/SU, that same plan could cover  only 30 hospital days and 20 outpatient office visits per year and impose  50 percent coinsurance for outpatient office visits.

Congress passed MHPAEA in 2008 to help address discrepancies in  health care coverage between mental illnesses and physical illnesses.  MHPAEA both strengthened and broadened federal parity requirements  enacted in 1996, including extending parity to cover the treatment of  substance use disorders. MHPAEA requires coverage for MH/SU  services—when those services are offered by group health plans  sponsored by large employers (generally employers with more than 50  employees)—be no more restrictive than coverage for medical/surgical  services. PPACA extended MH/SU parity requirements to individual  insurance plans and some small group health plans. See figure 1 for a  timeline of the laws and regulations establishing federal parity  requirements and the types of plans affected.

In general, MHPAEA requires that the financial requirements and  treatment limitations imposed on MH/SU benefits cannot be more  restrictive than the predominant financial requirements and treatment  limitations that apply to substantially all medical/surgical benefits.

Financial requirements. The most common types of financial  requirements include: (1) deductibles, which are required payments of a  specified amount made by enrollees for services before the issuer begins  to pay; (2) copayments, which are payments made by enrollees and are a  specified flat dollar amount—usually on a per-unit-of-service basis—with  the issuer reimbursing some portion of the remaining charges; (3)  coinsurance, which is a percentage payment made by enrollees after the  deductible is met and until an out-of-pocket maximum is reached; and (4)  out-of-pocket maximums, which are the maximum amounts enrollees  have to pay per year for all covered medical expenses.

Quantitative treatment limitations (QTL). QTLs are treatment  limitations that can be expressed numerically, such as annual, episode,  and lifetime day and visit limits. For example, QTLs include annual limits  on the number of office visits an enrollee can make for a certain condition  and lifetime limits on the coverage of benefits for a certain type of  treatment.

Non-quantitative treatment limitations (NQTL). NQTLs are non- numerical limitations on the scope or duration of MH/SU services.  Common NQTLs include (1) medical management standards that limit or  exclude benefits based on medical necessity or medical appropriateness,  or based on whether the treatment is experimental or investigative; (2)  refusal to pay for higher-cost therapies until it can be shown that lower  cost therapy is not effective—known as fail first or step therapy protocols;  (3) exclusions based on failure to complete a course of treatment; (4)  standards for providers to be admitted to participate in a network,  including the factors used to set provider reimbursement rates; and (5)  requiring pre-authorization of services—the requirement that an enrollee  receives prior approval for care.

The MH/SU parity regulations established a two-part analysis to  determine if the financial requirements or QTLs in a plan are in  compliance with MH/SU parity requirements. The first test determines if  a particular type of financial requirement or QTL (such as a copay)  applies to substantially all medical/surgical benefits in the relevant  classification of benefits (e.g., inpatient in-network or outpatient out-of- network). Generally, a financial requirement or QTL is considered to apply  to “substantially all” medical/surgical benefits if it applies to at least two- thirds of the medical/surgical benefits in the classification, according to  the regulations. Once the first test is met, the second test checks for  parity in the level or magnitude of the requirement (e.g., copay of $15 or  $20 or treatment limit of 21 or 30 inpatient days per episode). Specifically,  by regulation, the financial requirement or QTL cannot exceed the  predominant level—that is, the level that applies to more than half of the  medical/surgical benefits subject to the financial requirement or QTL in  the classification. For example, if at least two-thirds of outpatient, in- network, medical/surgical benefits are subject to a copay, and 75 percent  (i.e. more than half) of outpatient, in-network visits involving  medical/surgical benefits are subject to a copay of $30, the copay for  outpatient, in-network visits involving MH/SU benefits cannot exceed $30.

The MH/SU parity regulations extended parity requirements to NQTLs  and establish a different test for assessing parity of NQTLs between  medical/surgical and MH/SU benefits. Under the regulations, a plan  generally cannot apply an NQTL on an MH/SU benefit unless—both as  written and in operation—it is comparable to and applied no more  stringently than the NQTL applied to medical/surgical benefits.  According to guidance issued by HHS, DOL, and Treasury, the NQTL  analysis in the regulations focuses on the underlying factors (such as  processes, strategies, and evidentiary standards) used to apply the NQTL  and ensuring there are not arbitrary or discriminatory differences in how a  plan or issuer applies those factors to MH/SU benefits as compared to  medical/surgical benefits.

HHS, DOL, and Treasury share joint oversight responsibilities for certain  federal laws applicable to private health coverage, including MHPAEA.  The oversight of plans and issuers for compliance with MHPAEA is split  between the states, HHS, DOL, and Treasury, depending on the type of  coverage and whether the plan is self-funded or fully insured.

Individual and fully insured group plans sold by issuers. States have  primary responsibility for regulating insurance, and health insurance  products sold within a state must meet both federal and state  requirements, including MH/SU parity requirements. States oversee  health insurance sold by issuers (1) in the individual market, where  individuals purchase private health insurance plans directly from an issuer  or through an exchange; and (2) in the group market, where a plan  sponsor (typically an employer) purchases coverage from an issuer. Of  the estimated 216 million Americans who were enrolled in private health  insurance in 2016, the estimated enrollment in these state-regulated  markets was 17.3 million in the individual market, 14.2 million in the small  group market, and 42.9 million in the large group market. State  oversight of health insurance applies only to fully insured health plans  offered by state-licensed issuers. Because self-funded plans are financed  directly by the plan sponsor, these plans are generally not subject to state  law or oversight.

With respect to health insurance issuers selling products in the individual  and fully insured group market, HHS has primary enforcement authority  over MH/SU parity requirements in two instances: (1) when a state  notifies HHS that it does not have the authority to enforce MH/SU parity  requirements or the state notifies HHS that it is not otherwise enforcing  the requirements, or (2) when HHS determines the state failed to  substantially enforce MH/SU parity requirements. States falling into these  categories are known as direct enforcement states, and, in these states,  the Centers for Medicare & Medicaid Services (CMS) within HHS  assumes the responsibility for directly enforcing federal MH/SU parity  requirements and other federal health laws covered by PPACA with  respect to issuers. CMS is currently responsible for enforcing MH/SU  parity requirements against issuers in four states: Missouri, Oklahoma,  Texas, and Wyoming. While CMS enforces MH/SU parity requirements  and other PPACA requirements for these direct-enforcement states,  these states maintain enforcement authority over issuers for state-level  regulatory requirements.

For the estimate of overall enrollment in private health plans in 2016, see U.S. Census  Bureau, “Coverage Numbers and Rates by Type of Health Insurance: 2013 to 2016,”  Current Population Survey, 2014 to 2017 Annual Social and Economic Supplements, table  1. products they offer, DOL oversees the plans themselves for compliance  through its Employee Benefits Security Administration (see table 1).  DOL does not have the authority to enforce MH/SU parity requirements  directly against issuers to correct noncompliant health policies that are  designed, marketed, and sold by the issuer to numerous employers for  the purposes of offering health plans to their employees. DOL has  primary authority for overseeing compliance with MH/SU parity  requirements for self-funded, private employer-sponsored group plans, as  states generally do not have authority over these plans. The Internal  Revenue Service (IRS) within Treasury is authorized to impose an excise  tax on employers that sponsor private group plans that are not in  compliance with MH/SU parity requirements.

Similarly, HHS has primary authority for MH/SU parity requirements over  employer-sponsored plans for state and local governments—known as  non-federal governmental plans. Within HHS, CMS oversees both fully  insured and self-funded non-federal governmental plans. In 2017, an  estimated 13 million state and local government employees enrolled in  these plans. Sponsors of self-funded, non-federal governmental plans  may elect an exemption from, or “opt-out” of, certain federal health care  requirements, including MH/SU parity requirements. If a plan elects to  opt-out of MH/SU parity requirements, CMS also reviews the plan’s  election to ensure they meet requirements for doing so.

Practices for Overseeing Compliance with MH/SU Parity Requirements Vary among State and Federal Agencies

Nearly All States Reported Some Review of Fully Insured Group and Individual Plans for MH/SU Parity Compliance before Consumers Enroll; Post-Enrollment Reviews Vary

Through our survey and interviews with officials from the three selected  states, we found that nearly all states conduct some type of review for  MH/SU parity compliance as part of their oversight of issuers selling fully  insured large and small group plans and individual plans. The reported  type and frequency of these reviews vary, particularly for the reviews  conducted after consumers enroll in plans.

A product is a discrete package of health insurance coverage benefits that are offered  using a particular product network type (e.g., health maintenance organization or preferred  provider organization) within a service area. Issuers then sell plans to consumers by  pairing health insurance coverage benefits with a particular cost sharing structure,  provider network, and service area.

The only two states that did not report that they conduct reviews for MH/SU parity  compliance before products are approved for sale in their states are Missouri and  Wyoming, which are two of the four states where CMS is directly enforcing MH/SU parity  requirements. In the four direct enforcement states, CMS conducts reviews of issuer  policies and documentation for compliance with federal MH/SU parity requirements before  products are approved for sale in the states. The two other states—Texas and  Oklahoma—reported in our survey that they review products for state-level MH/SU parity  compliance; however, CMS maintains primary authority for reviewing products for  compliance with federal MH/SU parity requirements in those states. consumers enroll in a plan. Additionally, according to CMS officials,  the HHS mental health parity tool is not designed to facilitate an  evaluation of NQTLs due to the nature of reviewing NQTLs.

State oversight after consumers enroll in plans. In addition to the  review they conduct prior to consumers enrolling in plans, 27 states  reported in our survey they have conducted some type of review related  to MH/SU parity after consumers enroll. The types of reviews states  conduct vary. These review types include: targeted reviews based on  consumer complaints or other information, random audits, and conducting  broad routine reviews of issuers’ compliance with state and federal health  insurance laws—called market conduct examinations. Through our  interviews of states and stakeholders we identified additional enforcement  activities some states are using to assess the issuer compliance with  MH/SU parity requirements after consumers enroll. These reviews and  additional enforcement activities are described below:

Conducting targeted reviews. Twenty states reported in our survey  that they had conducted a targeted review that focused on specific  issuers or particular MH/SU parity compliance concerns, while other  states reported they had never performed such a review. Consumer  complaints were most commonly identified as the reason—at least in  part—that these 20 states conducted targeted reviews to assess  compliance with MH/SU parity requirements. Thirty-eight states  reported in our survey that they track MH/SU parity complaints, which  can be submitted by consumers, providers, or advocates. For  example, after receiving consumer complaints, Massachusetts  examined the accuracy of the information on behavioral health  services—services that address mental health or substance use  issues—contained in issuers’ provider directories and compared this  to the accuracy of medical/surgical provider information in a 2018  report. Officials from another state told us they frequently use targeted  reviews in response to complaints because these focus on a specific  issue, rely on more recent data, and are less time consuming than  more comprehensive market conduct examinations that review an  issuer’s compliance with all state health requirements. States reported  additional reasons for starting targeted reviews related to MH/SU  parity requirements, including reviews initiated after receiving referrals  from other departments, reviews driven by predictive analytics or  market analyses, and reviews in response to media attention. In 2017  and 2018, the frequency of receiving MH/SU parity-related complaints  and conducting targeted reviews varied across states. (See table 2).

Market conduct examinations. Nearly all states conduct market  conduct examinations and states have not routinely included a review  for MH/SU parity compliance as part of the examinations. Market  conduct examinations are a review of an insurer’s marketplace  practices. The examination is an opportunity for the state to verify  data provided by the insurer and to confirm that companies’ internal  controls and operational processes result in compliance with state  laws and regulations. Eighteen states reported in our survey that they  routinely conduct market conduct examinations (ranging from every 3  or 5 years), and, of those, nine states reported that they usually or  always include a review of MH/SU parity compliance. Twenty-nine  states reported that their market conduct examinations are not  routine; they are conducted on an as-needed basis or in response to  risk factors, such as market analysis or complaints. In order to assist  states’ ongoing oversight of MH/SU parity compliance, NAIC  developed guidance on MH/SU parity for its Market Regulation  Handbook, which most states use to guide their market conduct  examinations, an NAIC official told us. The guidance includes a data  collection tool for mental health parity analysis. While the guidance  was finalized in August 2019, an NAIC official told us most states  were already using the guidance to conduct their market conduct  examinations while it was in draft form.

State-wide comprehensive reviews of issuers. Officials we  interviewed from two of the three selected states told us they have  conducted reviews of all issuers in their state as part of their oversight  of MH/SU parity compliance after consumers enroll in plans. For  example, as requested by its state legislature, Maryland conducted  three annual MH/SU parity surveys with the state’s major issuers.  Maryland officials told us the first two surveys focused on MH/SU  parity compliance in the issuers’ plan documentation, and the last  survey assessed compliance in plan practices and operations.  Maryland officials told us the review of all issuers in the state will give  them a baseline understanding of issuer compliance with MH/SU  parity requirements reviewed. Officials from Washington told us they  are using a CMS grant to evaluate issuer claims data and to  understand issuers’ NQTLs in operation, which officials say will  enable them to identify statewide MH/SU parity-related concerns.

Annual compliance reporting. At least eight states have established  annual requirements for issuers to demonstrate their MH/SU parity  compliance through data reporting or self-certifications, according to  officials from one of the three selected states in our review and a  provider organization. To fulfill the states’ requirements, issuers  submit information such as the percentage of claims paid for in- network and out-of-network MH/SU services compared to those paid  for medical/surgical services and the number of consumers denied  prior authorizations for MH/SU services. For example, in 2012,  Massachusetts began requiring issuers to submit annual reports  certifying that their plans comply with federal and state MH/SU parity  requirements and instructing issuers to compare denials of care for  MH/SU and medical/surgical services, among other things. These  certifications must be signed by the issuer’s chief executive officer  and chief medical officer, which Massachusetts officials told us  ensures that issuer leadership is aware of the MH/SU parity  requirements. Additionally, an official from NAIC told us that NAIC  now includes data reporting requirements related to MH/SU parity,  such as requiring information on prior authorizations and denials of  care, in its annual nationwide collection of issuers’ post-enrollment  information. An NAIC official told us states can use these data to  compare information on MH/SU and medical/surgical services and  examine issuers that operate in multiple states.

In their survey responses, 47 states identified enforcement actions they  can take if they find, through a review, that an issuer violated MH/SU  parity requirements. States reported that these enforcement actions  include: financial penalties, license termination, orders to pay claims or  interest, and orders to pay restitution. However, an official from NAIC  told us that in the majority of cases, issuers voluntarily come into  compliance after state regulators identify an issue or parity violation.

DOL and CMS Conduct Targeted Oversight of Employer-Sponsored Group Plans after Receiving Information and Complaints about Possible Noncompliance

Both DOL and CMS oversee employer-sponsored group plans to ensure  their compliance with MH/SU parity requirements. Specifically, the  agencies conduct what are known as targeted reviews after consumers  enroll in these plans. The agencies initiate these reviews after they  receive complaints or other information regarding possible noncompliance  with either MH/SU parity requirements or other, unrelated issues, such as  a plan failing to provide a document explaining the health benefits  covered. Unlike states, the agencies do not conduct any type of review of  employer-sponsored plans before consumers enroll and do not have the  authority to conduct such a review, according to DOL and CMS officials.

DOL oversight. DOL’s targeted reviews are triggered by inquiries,  including complaints, or other information that identifies possible  noncompliance with MH/SU parity requirements or other applicable  federal health care laws. These targeted reviews can also originate from  additional techniques DOL uses to target plans for review, such as  reviewing bankruptcy filings or financial and operational information filed  annually by employers. According to DOL’s enforcement manual, DOL  investigators generally identify the reasons for starting each review,  obtain relevant information from the plan or issuer, and conduct a full  review of compliance with applicable federal health care laws. These  reviews which are performed by DOL’s 10 regional offices can focus on  specific private, employer-sponsored group plans, service providers (such  as third party administrators), or issuers; however, DOL does not have  the authority to take direct enforcement actions against issuers for  violations of MH/SU parity requirements.

DOL reported that it completed 302 reviews of private, employer- sponsored group plans that included a review for compliance with MH/SU  parity requirements in fiscal years 2017 and 2018. According to DOL  officials, these reviews can take 2 to 3 years to complete and  investigators follow an extensive compliance checklist to conduct these  reviews. The checklist includes specific questions to help determine  compliance with all applicable requirements, including a section with  questions on MH/SU parity. Because investigators complete the  compliance checklist for every plan level health investigation, reviews not  triggered by a parity complaint may still uncover a parity violation. For  example, DOL might review a private employer-sponsored group plan in  response to a consumer complaint about how long the plan covered a  hospital stay for a mother and her newborn. The review would include a  review of compliance with the related law (the Newborns’ and Mothers’  Health Protection Act of 1996), MH/SU parity-related requirements, and  all other applicable federal health care requirements.

Nearly all DOL reviews that assess compliance with MH/SU parity  requirements originate from sources unrelated to MH/SU parity, including  complaints or other information about potential noncompliance with other  federal health care laws and DOL reviews of the annual financial and  operational information filed by employers, based on data provided by  DOL on the reasons targeted reviews were opened. DOL received few  MH/SU parity complaints and opened few reviews based on a potential  MH/SU parity violation, compared to complaints related to other federal  health requirements, in fiscal years 2017 and 2018 (see table 3).

When DOL identifies a violation of MH/SU parity requirements through  one of its reviews, investigators first seek to bring the private employer- sponsored group plan or issuer into compliance voluntarily, according to  DOL officials. When that is not possible, DOL can sue the plan for  equitable relief, which can result in the plan being required to reimburse  members whose claims were improperly denied. DOL can also request  that the Treasury levy an excise tax on the non-compliant private  employer-sponsored group plan, but DOL officials noted that the excise  tax goes to the Treasury rather than toward payment of claims for plan  members, and DOL’s focus is on obtaining payment of claims. DOL  officials told us they have never referred a plan to IRS to levy an excise  tax based on an MH/SU parity violation. The 21st Century Cures Act  requires DOL to conduct an audit of a private employer-sponsored group  plan when DOL has identified five or more MH/SU parity violations;  however, DOL officials told us the use of this authority has not been  triggered, as of October 2019.

DOL identified audit resources challenges faced by the agency given the  universe of plans DOL oversees and reported that the agency is taking  steps to better leverage its resources through targeted exams in its  September 2019 enforcement report to Congress. Specifically, DOL  reported that DOL has less than one investigator for every 12,500  employee benefit plans the agency oversees, including private health,  pension, life, and disability insurance. In light of these challenges, DOL  officials said they are focusing their targeted reviews on issuers and other  service providers to obtain voluntary corrections whenever possible so  they can address noncompliance across multiple private employer- sponsored group plans. To date, they have completed at least two  investigations at the issuer level and brought an issuer into voluntary  compliance after one investigation identified MH/SU parity noncompliance  affecting over 4,000 private, employer-sponsored group plans and 7  million consumers. According to DOL officials, focusing on issuers will  result in their opening fewer targeted reviews than in prior years, but will  have more meaningful results. DOL officials also noted other efforts  underway to assist in MH/SU parity oversight. For example, the DOL’s  Kansas City Regional Office has convened a task force that focuses on  parity in opioid use disorder treatment coverage. DOL officials told us  they require senior advisors in each of the 10 regions to identify trends in  the types of violations DOL identifies and to identify when a violation  could be happening at the issuer level, rather than the individual  employer-sponsored group plan level.

CMS oversight. CMS oversight of employer-sponsored, non-federal  governmental plans for compliance with MH/SU parity requirements  consists of targeted reviews. Like DOL, these targeted reviews originate  from complaints or information about noncompliance—about MH/SU  parity or issues with other federal health care laws. The reviews are used  to assess compliance with all applicable health requirements, and CMS  officials told us CMS has broad authority to review or request information  as a part of these reviews. However, according to CMS officials, CMS  has limited authority to review or request information from these plans  outside of these targeted reviews. Specifically, CMS officials said CMS  does not have the authority to conduct random audits, reviews, or  examinations of employer-sponsored, non-federal governmental plans, or  to require the plans to provide documentation to demonstrate compliance  with MH/SU parity requirements. CMS officials also said they do not have  the authority to review employer-sponsored, non-federal governmental  plans for compliance with MH/SU parity requirements prior to enrollment.

While large, self-funded, employer-sponsored, non-federal governmental  plans may opt-out of MH/SU parity requirements and certain other federal  health requirements, CMS may identify MH/SU parity noncompliance if  these plans did not properly opt-out. CMS officials told us that they review documentation for all plans that elect to opt out of MH/SU parity  requirements to ensure it was properly submitted. If CMS finds a plan  may have opted-out incorrectly, CMS officials said they can request  additional information from the plan and can ultimately decide the opt-out  was invalid.

CMS reported that it closed five reviews related to MH/SU parity in fiscal  years 2017 and 2018. Two targeted reviews originated from MH/SU parity  complaints and three reviews were related to plans opting-out of MH/SU  parity requirements. CMS officials told us that they received four  complaints related to MH/SU parity in employer-sponsored, non-federal  governmental plans in fiscal years 2017 and 2018. The officials told us all  four complaints resulted in targeted reviews, two of which were ongoing  as of September 2019.

When CMS identifies MH/SU parity noncompliance through one of these  targeted reviews, the agency takes one of several actions: working with  the plan to implement a corrective action plan; initiating a full market  conduct examination of the plan; or imposing civil money penalties. Like  DOL, the 21st Century Cures Act requires CMS to audit an employer- sponsored, non-federal governmental plan or issuer when CMS has  identified noncompliance five or more times. According to CMS officials,  as of November 2019, the use of this audit authority has not been  triggered.

DOL and CMS Do Not Have Assurance That Their Use of Targeted Reviews to Oversee MH/SU Parity Requirements Is Effective for Ensuring Parity

Under DOL’s and CMS’s oversight through targeted reviews, self-funded  employer-sponsored group plans do not undergo review for compliance  with MH/SU parity requirements unless the agencies receive complaints  or other information about potential noncompliance with an applicable  federal health care law, or the review is opened as a result of a targeting  technique unrelated to MH/SU parity—such as bankruptcy filing review.  Relying on the receipt of such information to trigger a targeted review of  MH/SU parity is a concern given the low number of complaints DOL  receives related to MH/SU parity when compared to other federal health  requirements. For example, as we have noted, DOL received 129  complaints in fiscal year 2018, and most of the noncompliance with  MH/SU parity requirements DOL identified was found through reviews  triggered by complaints and information unrelated to MH/SU parity in  fiscal years 2017 and 2018, based on our review of DOL data. Further, as  discussed later in this report, consumer advocates have noted that there  is a lack of consumer awareness about MH/SU parity requirements,  which may result in fewer complaints than would otherwise be made if  consumers understood the requirements.

Federal internal control standards state that agencies should identify,  analyze, and respond to risks related to achieving their defined  objectives. DOL has stated that its defined objective is the full  implementation of MH/SU parity requirements through vigorous  compliance assistance and enforcement. HHS has stated that it is  committed to enforcing MH/SU parity requirements through CMS and to  providing the sponsors of employer-sponsored, non-federal governmental  plans the information needed to ensure that the plans are fully compliant  with MH/SU parity requirements.

DOL and CMS officials told us they have not completed any statistical  analysis or study regarding the effectiveness of their targeted review  approach to MH/SU parity compliance, nor whether this approach  increases the risk of noncompliance. Specifically, they have not  analyzed whether relying on targeted reviews alone increases the risk of  noncompliance with MH/SU parity requirements in employer-sponsored  group plans. The risk of noncompliance may be increased because  incentives for plans to comply are limited when investigations are initiated  only after receiving complaints or information about noncompliance. DOL  and CMS officials also said they have not analyzed whether additional  strategies, such as the attestation or issuer documentation requirements  used by some states, would reduce the risk of noncompliance. For  example, such an evaluation could assess whether a sample of health  plans reviewed for compliance identified similar types of noncompliance  as those identified when plans were reviewed in response to MH/SU  parity complaints. According to officials from a provider organization, one  such strategy to improve compliance would be to require issuers or plans  to affirm that (1) their plans comply with MH/SU parity requirements and  (2) they have documentation showing that they analyzed their plans for  compliance. According to these officials, requiring this documentation  from plans and issuers can increase compliance, even if there is a low  probability that a plan will be audited. DOL and CMS officials told us that  they currently do not have the authority to conduct oversight activities of  this type. Specifically, they told us that for self-funded private or non- federal governmental employer-sponsored group plans they do not  currently have the authority to: (1) review plans for compliance with  MH/SU parity requirements before coverage is offered to consumers, (2)  require plans to develop documentation to demonstrate compliance with  MH/SU parity requirements, and (3) monitor or examine plans for  compliance with MH/SU parity requirements outside of an investigation.

Without evaluating the effectiveness of their targeted review approach,  DOL and CMS do not know whether their oversight is adequate for  ensuring compliance with MH/SU parity requirements, or whether they  need to adopt additional strategies and seek new authorities, if needed.

Enforcement Activities and Research Identified Some Health Plans Not Compliant with MH/SU Parity Requirements, but the Extent of Compliance Is Unknown

States, DOL, CMS, and Available Research Identified Some Noncompliance with MH/SU Parity Requirements

States, DOL, and CMS identified some plan or issuer noncompliance with  specific MH/SU parity requirements in 2017 and 2018 through their  various oversight efforts. Specifically, after consumers enrolled in plans:

Seventeen of the 51 states that responded to our survey reported  identifying noncompliance a total of 254 times among issuers of  individual plans and fully insured, employer-sponsored group plans.

DOL reported identifying noncompliance 113 times among private,  employer-sponsored group plans or the issuers of these plans.

CMS reported identifying noncompliance two times among employer- sponsored, non-federal governmental plans.

Both states and DOL most commonly identified noncompliance with  MH/SU parity NQTL requirements. Eleven of the 14 states that provided  information on the types of MH/SU parity noncompliance in our survey  reported that the noncompliance they found was related to NQTLs half  the time or more. Similarly, DOL reported that 55 percent of  noncompliance the agency found in fiscal year 2018 was related to  NQTLs, while 40 percent was related to financial requirements or QTLs.  Through our review of DOL letters informing plans of noncompliance, we  found that the most common types of noncompliance with MH/SU parity  requirements were related to (1) copayments or coinsurance, such as a  higher copayments for MH/SU treatment than those generally applied to  equivalent medical/surgical treatment (a financial requirement); (2) prior  authorizations, such as requiring approval in advance for MH/SU  treatment but not requiring it for equivalent medical/surgical treatment (an  NQTL); and (3) the total number of treatments allowed, such as a limit on  inpatient hospital days for MH/SU treatment that is not applied to  equivalent medical/surgical treatment (a QTL).

The scope of noncompliance with MH/SU parity requirements identified  by states, DOL, and CMS in 2017 and 2018 varied—both in terms of the  number of consumers affected and the steps needed to come into  compliance. While MH/SU parity requirements apply to plans, regulators  may identify and seek to correct noncompliance in the underlying health  policies that issuers use to design, market, and sell as health plans to  numerous employers. For example, DOL letters show one particularly  widespread violation affected more than 7 million enrollees. Most plans or  issuers resolved the noncompliance identified by regulators voluntarily.  For example, DOL officials told us that plans or issuers resolved all  instances of noncompliance voluntarily. Nine states reported in our survey  taking a total of 20 enforcement actions to bring plans or issuers into  compliance in 2017 and 2018. See table 4 for examples of  noncompliance and steps required to come into compliance.

Additionally, while the literature we reviewed suggested that the  individual, small group, and large group plans assessed by the studies  were generally compliant with MH/SU parity requirements assessed by  the studies, the studies identified some noncompliance or possible  noncompliance. For example:

One case study found that, in 25 percent of the total products offered  on two state-based health insurance exchanges between October  2013 and March 2014—the first year of operation for the exchanges  established by PPACA—the financial requirements and certain  NQTLs reviewed appeared to be noncompliant with MH/SU parity  requirements. The study also found variation in the types of  noncompliance in each of the states. The case study concluded that  on one exchange more than half the products appeared inconsistent  with MH/SU parity requirements, particularly the NQTLs reviewed; on  the other exchange, 11 percent of the products had a financial  requirement that violated MH/SU parity requirements.

One study found that 18 percent of benchmark plans were not  compliant with MH/SU parity requirements for substance use disorder  benefits specifically. For example, five plans had limits on the  number of inpatient and/or outpatient visits for substance use disorder  services only. (See app. II for additional information about the  studies we reviewed.)

Each of the studies we reviewed were limited because they evaluated  only selected requirements, with the authors of four studies noting there  was insufficient information in plan documents to evaluate additional  MH/SU parity requirements. As such, none of the studies could  determine the extent of issuer compliance with all MH/SU parity  requirements.

A 2018 survey of employer-sponsored group plans suggests that there  could be employer-sponsored plans that have not come into compliance  with MH/SU parity requirements. Specifically, this nationally  representative survey of employers that offer employer-sponsored group  plans found that 61 percent of large and midsized employers reported  they had taken steps to address compliance with MH/SU parity  requirements—such as reviewing plan documents. An additional 13  percent of large and midsized employers reported that they planned to  take action to come into compliance and some plans may have already  been in compliance.

Stakeholders and Research Reviewed Indicate the Full Extent of Compliance with MH/SU Parity Requirements is Not Known

According to advocacy groups and state and federal officials we  interviewed and some of the research we reviewed, the full extent of  compliance with MH/SU parity requirements is not known. As NAIC and  consumer advocacy stakeholders have reported, regulators often rely on  both individual complaints and aggregate consumer complaint statistics to  identify problem issuers and problem areas for additional oversight.  However, stakeholders from eight consumer advocacy groups told us that  complaints are not a good measure of whether MH/SU parity issues exist  and do not accurately reflect the number of enrollees facing problems  with parity. Further, CMS, DOL, and state officials, as well as  stakeholders and researchers, also noted the complexity of assessing  plans for MH/SU parity compliance for NQTLs in particular, which may  result in inconsistent identification of MH/SU parity violations or the  inability to fully assess compliance.

Limitations of relying on complaints to trigger enforcement  activities. Stakeholders and state officials reported on the limitations of  relying on complaints to trigger enforcement activities—which contribute  to the challenges in determining the full extent of compliance with parity  requirements. Stakeholders from eight consumer advocacy groups told us  that if regulators rely on complaints to identify possible noncompliance  after consumers enroll in plans, they will not know the full extent of  compliance with MH/SU parity requirements. These stakeholders  identified several reasons complaints do not accurately reflect the number  of consumers facing problems related to plan or issuer compliance with  MH/SU parity requirements:

Consumers may not be aware of MH/SU parity requirements, such as  how to determine if the treatment challenge they are experiencing is a  potential parity violation, how to file a parity-related complaint, or  which entity they should contact to file a complaint, according to five  consumer advocacy stakeholders we spoke to and one professional  organization. For example, while a consumer would be aware of a  denial for a particular treatment for a mental health condition because  the issuer did not consider it to be medically necessary, the consumer  could not easily determine if this standard was applied more  stringently than to similar medical/surgical benefits and thus signaled  a parity issue. Further, in our survey, officials from 21 states  reported they do not provide any public information to consumers  about MH/SU parity requirements, which may contribute to a general  lack of consumer awareness in these states.

Consumers may decide not to file a complaint due to the stigma  associated with MH/SU treatment, three consumer advocacy  stakeholders and state officials in one state told us. One stakeholder  also noted that consumers expect substance use disorder services to  be treated differently than medical services and are therefore less  likely to file a complaint if they receive disparate treatment.

Consumers may be hesitant to file a complaint that includes sensitive  personal details, such as a mental illness diagnosis, two stakeholders  told us. One of these stakeholders told us consumers in need of  substance use disorder services in particular may not want to raise a  complaint that documents their participation in illegal activities, such  as drug misuse. In addition, two stakeholders and state officials in one  state stated that individuals or families experiencing an immediate  crisis associated with MH/SU conditions may not be well-equipped to  navigate the complaint process or wait for a complaint resolution.

Providers face barriers helping consumers file complaints or appeals  related to MH/SU parity requirements, four consumer advocacy  stakeholder groups and one professional organization told us. The  barriers identified by these stakeholders include: providers being  unable to file complaints on behalf of consumers in some states; the  time consuming nature of the appeals or complaint processes; and  provider fear that an issuer will drop them from their network if they  file a complaint. Two consumer advocacy groups have identified that  providers may be in a better position to understand a denial decision  and justify a consumer’s need for treatment, but noted that barriers  discourage providers from filing an appeal or complaint. One of these  consumer advocacy groups reported that providers might be unaware  of what issuer actions would violate MH/SU parity requirements.

Officials from the three selected states provided examples of specific  efforts taken that may address stakeholder identified challenges  consumers face in understanding parity requirements and filing related  complaints. For example, Maryland officials told us they developed a  webinar to help consumers with filing complaints related to substance use  disorder treatment. Officials from Massachusetts told us they review for  parity violations any complaint related to coverage of mental health- related services, regardless of whether the consumer indicates that the  complaint might be a parity violation. While this process is still dependent  on a consumer to make a complaint, it does not rely on the consumer  having an in-depth understanding of parity requirements for their  complaint to be reviewed for potential noncompliance. In light of concerns  about consumers not filing complaints, officials from Washington told us  their statewide comprehensive review includes an assessment of how  issuers implemented state and federal MH/SU parity requirements and  aims to help them assist consumers who are not reaching out directly.  Additionally, 30 states reported in our survey that they provide public  information—such as frequently asked questions or brochures—for  consumers about MH/SU parity requirements.

Complexity of assessing NQTLs for MH/SU parity compliance. CMS,  DOL, NAIC, and state officials, as well as some stakeholders and  researchers, identified complexities in assessing NQTLs for compliance  with MH/SU parity requirements. As a result, regulators may fail to identify  noncompliance, or may not always identify noncompliance, making  current numbers on noncompliance with MH/SU parity requirements an  unreliable indicator of the extent of noncompliance.

Difficult to assess plan implementation of NQTLs. Officials from  three states reported in our survey or interviews that it is challenging  to determine how an NQTL described in plan documents is actually  being implemented and experienced by consumers in practice. This  can make it difficult to determine both if noncompliance has occurred  and the extent of any noncompliance. Further, some state regulators  do not conduct the types of detailed analyses necessary to determine  if an NQTL is in compliance with MH/SU parity requirements,  according to one consumer advocacy group. Finally, four studies we  reviewed identified that researchers were unable to observe the plans’  implementation of NQTLs. Thus, they were unable to draw  conclusions about whether or not the way plans implemented the  NQTLs complied with MH/SU parity requirements. To address the  complexities of these analyses for their own reviews, DOL officials  told us that for its targeted reviews of MH/SU parity compliance, DOL  uses seasoned investigators, early litigation support, technical  guidance from DOL’s regulations office, and outreach to other federal  and state agencies.

Lack of documentation on medical/surgical NQTLs. A lack of  documentation on the factors used to apply NQTLs to  medical/surgical benefits makes it difficult for issuers to demonstrate  compliance with MH/SU parity requirements, according to two industry  officials. They told us that information on NQTLs—such as when to  require prior authorization—has to be created for medical/surgical  benefits so that the information can then be compared to the  application of NQTLs to MH/SU benefits to assess compliance with  MH/SU parity requirements. One industry official noted that this poses  an additional hurdle when MH/SU benefits are carved out or  separately managed from the rest of a health plan. This lack of explicit  information about medical/surgical benefits and difficulty drawing  parallels between medical/surgical and MH/SU care also makes it  difficult for regulators to determine parity compliance, officials from  one of the three selected states told us.

Lack of resources. Eight states reported in our survey that lack of  staff resources, staff training, or clinical expertise are additional  challenges to assessing compliance with MH/SU parity requirements.  Further, states may hesitate to determine an issuer violated federal  MH/SU parity requirements due to a lack of confidence or clarity in  applying the federal laws and may cite state laws instead, according  to officials from one of our three selected states and a provider  organization. Officials from the provider organization told us this could  result in an undercount of MH/SU parity violations if a state cites a  potential violation of an MH/SU parity requirement as a violation of a  state law unrelated to federal MH/SU parity requirements. One state  official identified consumer protection laws as an alternative to  pursuing possible MH/SU parity requirement violations. Officials from  one state told us some state laws have more clear cut standards than  federal MH/SU parity requirements, due to the lack of clarity regarding  federal MH/SU parity requirements. However, different strategies  were used in three states to obtain the needed clinical expertise to  review NQTLs, including regular meetings with clinicians from the  state mental health department and using grant money to contract  with physicians with clinical expertise to help with compliance reviews.

HHS, DOL, and Treasury Jointly Develop Guidance and Provide Support to States for Enforcing MH/SU Parity Requirements

HHS, DOL, and Treasury have coordinated on oversight of MH/SU parity  requirements by providing support and jointly developing guidance for  state regulators, insurance industry officials, providers, and consumers.  HHS described several recent and planned coordination activities in its  public action plan to improve state and federal coordination of the  oversight of MH/SU parity requirements. This plan was required by the  21st Century Cures Act. Recent and ongoing support and coordination  activities include:

Formal agreements with states. HHS and DOL officials told us they  have established formal agreements—such as collaborative  enforcement agreements—with states to help coordinate, share  information about, or assist states with MH/SU parity enforcement  activities. For example, DOL officials told us they have general  enforcement and common interest agreements with nearly 40 states  that allow them to share information related to MH/SU parity  enforcement. HHS officials told us they have collaborative  enforcement agreements with six states that allow HHS to intervene if  a state’s efforts to bring an issuer into compliance with MH/SU parity  requirements are unsuccessful. In response to our survey, state  officials reported few formal referrals between the states and HHS or  DOL.

Informal communication with states. HHS and DOL officials told us  that state regulators can contact regional coordinators and individuals  in their respective headquarters for assistance with MH/SU parity  enforcement outside of formal agreements. HHS and DOL officials  told us that referrals of specific complaints are informal and  infrequent, noting that if a complainant contacted their office by  mistake they would provide the contact information for the appropriate  state or federal agency.

Technical assistance and outreach. HHS and DOL jointly conduct  technical assistance for state regulators and have conducted outreach  with stakeholders, including consumers, consumer advocates,  providers, issuers, and employers, to improve compliance with MH/SU  parity requirements. DOL officials told us that they meet regularly with  state regulators and NAIC to provide technical assistance and foster  implementation and enforcement coordination. For example, in 2017,  HHS and DOL held a commercial market parity policy academy— technical assistance for teams of state officials on strategies to  advance MH/SU parity compliance and lessons learned from other  states’ implementation efforts. According to the HHS action plan,  representatives from 20 states and territories attended. Additionally,  DOL held a roundtable discussion with stakeholders to discuss  NQTLs, disclosure, and federal-state coordination in January 2019.

Grant funding. HHS has also awarded funding, provided by PPACA,  to states to help improve oversight of MH/SU parity requirements. In  2016, CMS awarded $9.3 million to 20 states specifically for  enforcement and oversight related to MH/SU parity. Maryland, for  example, used these funds to create a position specific to MH/SU  parity oversight, which the state made permanent after the funding  period ended. In 2018, CMS awarded funding through the State  Flexibility to Stabilize the Market Grant Program that focused on  supporting state implementation and planning around several PPACA  market reforms and consumer protections. Washington, for example,  is using this grant to review issuer’s implementation of state and  federal MH/SU parity requirements and to assess access to MH/SU  treatment.

HHS, DOL, and Treasury also coordinate with state regulators and NAIC  to issue guidance for stakeholders in an effort to increase understanding  of and compliance with MH/SU parity requirements. From December  2010 to September 2019, the three agencies issued 10 guidance  documents that included 58 frequently asked questions and answers  specific to MH/SU parity requirements. These guidance documents cover  a range of topics, including describing the types of plans covered by  MH/SU parity requirements, providing definitions of QTLs and NQTLs,  and using specific scenarios to show if a practice—such as requiring prior  authorization for certain medications to treat a substance use disorder—is  permissible under the law.

HHS, DOL, and Treasury have also developed guidance or support on  MH/SU parity aimed specifically at consumers. For example, as part of  HHS’s action plan, HHS developed a web-based portal to assist  consumers in identifying, based on the consumer’s insurance type, the  appropriate entity to contact for filing a parity-related complaint—HHS,  DOL, or state insurance regulators. See appendix III for examples of  guidance published by the agencies and the target audience.

States have reported that existing guidance and support from the  agencies helped states in their reviews of issuers for compliance with  MH/SU parity requirements; however, some states and other  stakeholders have identified a need for additional guidance. Specifically,  officials from 43 states reported in our survey that guidance or other  support from the agencies has helped inform state reviews of plans or  issuers for compliance with MH/SU parity requirements, and officials from  24 states reported in our survey that additional guidance or support is  needed. In written survey responses, state officials most commonly  identified the need for additional guidance around reviewing NQTLs. In  their comments for the 2017 HHS public listening session, some  stakeholders identified the need for additional compliance information.  Similarly, two industry stakeholders and one consumer advocacy  organization also told us that additional guidance around NQTLs would  be helpful to improve compliance with MH/SU parity requirements.

HHS, DOL, and Treasury issued additional guidance after seeking public  comment, as required by the 21st Century Cures Act. This guidance  covers the types of information plans must release to consumers or  providers related to MH/SU parity, known as disclosure requirements, and  NQTL requirements. Specifically, the guidance document contains (1)  answers to 11 additional frequently asked questions on NQTLs and  disclosure requirements and (2) a disclosure template consumers can  use to request MH/SU parity-related information from their employer- sponsored health plans and issuers of individual plans. Released in  September 2019, the guidance may address the concerns identified by  states and stakeholders.

Employer-sponsored group plan and issuer compliance with federal  MH/SU parity requirements is important to ensure that individuals seeking  MH/SU treatment do not face discriminatory practices. DOL’s and CMS’s  oversight of employer-sponsored group plan compliance with federal  health care laws is driven by information and complaints they receive  about potential noncompliance; however the agencies receive relatively  few consumer complaints about MH/SU parity and DOL refers a small  percentage of those complaints to its investigators. DOL’s and CMS’s  reviews of compliance with relevant federal health care laws—including  those related to MH/SU parity even when the origin of the investigation  was unrelated to MH/SU parity concerns—has enabled the agencies to  identify some plan and issuer violations of MH/SU parity requirements.  However, the frequency with which compliance issues are identified in  these reviews suggests that noncompliance with MH/SU parity  requirements may be common.

Given stakeholder-identified concerns with relying on complaints for  MH/SU parity, the complexity of MH/SU parity requirements, and the  limited complaints received in this area, DOL and CMS may not be  identifying and responding to the risks posed by the agencies’ oversight  approach. As a result, consumers may be enrolled in plans that fail to  comply with MH/SU parity requirements. Until DOL and CMS evaluate  whether the current approach of targeted oversight in response to  information received is effective for identifying compliance issues with  MH/SU parity, they will not know whether this approach is effective or  whether additional strategies are needed to help ensure that their  oversight meets their commitment to full implementation of MHPAEA.

We are making a total of two recommendations, including one to DOL’s  Employee Benefits Security Administration and one to HHS’s CMS.  Specifically:  The Assistant Secretary of Labor for the Employee Benefits Security  Administration should evaluate whether targeted oversight in response to  information received is effective for ensuring compliance with MH/SU  parity requirements. If this evaluation determines the current targeted  oversight approach results in significant program risks, the Employee  Benefits Security Administration should develop a plan to more effectively  enforce MH/SU parity requirements and if necessary seek additional  oversight authority, as warranted. (Recommendation 1)

The Administrator of CMS should evaluate whether targeted oversight in  response to information received is effective for ensuring compliance with  MH/SU parity requirements for non-federal governmental plans. If this  evaluation determines the current targeted oversight approach results in  significant program risks, CMS should develop a plan to more effectively  enforce MH/SU parity requirements and if necessary seek additional  oversight authority, as warranted. (Recommendation 2)

We provided a draft of this report to DOL, HHS, and Treasury for review  and comment. DOL and HHS both concurred with our recommendations.  DOL’s comments are reproduced in appendix IV and discussed below.  HHS’s comments are reproduced in appendix V and discussed below.  DOL, HHS, and Treasury also provided technical comments, which we  incorporated as appropriate.

In its written comments, DOL elaborated on its current strategy to review  its health enforcement program. Specifically, DOL noted that it reviews all  MH/SU parity-related investigation findings and case closings, and all  health plan investigations include a review of MH/SU parity requirement  compliance, regardless of the source or reason for the investigation. DOL  also stated that its current enforcement strategy to identify violations at  the plan level and seek corrections of systemic violations at the service  provider level has been successful. However, as explained in our report,  DOL has not analyzed whether relying on targeted reviews alone  increases the risk of noncompliance with MH/SU parity requirements in  private, employer-sponsored group plans. Such an evaluation could help  DOL identify and determine if additional enforcement strategies related to  MH/SU parity requirements are needed.

In its comments, DOL also noted its resource limitations. Specifically,  DOL stated that despite the Employee Benefits Security Administration’s  small size and limited resources, it is responsible for overseeing 2.4  million health plans, among other things. DOL noted that it will consider  GAO’s recommendation in light of its resource constraints. Given these  constraints, an evaluation could help ensure DOL’s resources are most  efficiently targeted.

In its comments, HHS stated that it is committed to enforcing MH/SU  parity requirements. HHS described its responsibilities for enforcement  and noted that it works with plans and issuers to help them understand  and comply with MHPAEA. HHS also stated that it collaborates with state  regulators, DOL, and Treasury in an effort to increase understanding and  compliance.

We are sending copies of this report to the appropriate congressional  committees, the Secretaries of Health and Human Services, Labor, and  Treasury, and other interested parties. In addition, the report is available  at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or DickenJ@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix VI.

Appendix I: Mental Health and Substance Use Disorder Parity Requirements in Medicaid and the State Children’s Health Insurance Program (CHIP)

Appendix I: Mental Health and Substance Use  Disorder Parity Requirements in Medicaid and  the State Children’s Health Insurance Program  (CHIP)

In 2016, the Centers for Medicare & Medicaid Services (CMS), an agency  within the Department of Health and Human Services, issued a final rule  addressing the application of the Paul Wellstone and Pete Domenici  Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to  Medicaid managed care organizations (MCO), Medicaid Alternative  Benefit Plans (ABP), and CHIP. Under this final rule, all beneficiaries  enrolled in Medicaid MCOs, ABPs, and CHIP are entitled to mental health  and substance use disorder (MH/SU) benefits that comply with certain  MH/SU parity requirements of MHPAEA, which generally requires that  MH/SU benefits be no more restrictive than medical or surgical benefits  when MH/SU benefits are offered.

The CMS final rule defines the role of the states in evaluating overall  compliance of state Medicaid and CHIP programs with MH/SU parity  requirements. The final rule establishes the processes by which states  must assess and document that their Medicaid and CHIP programs  comply with MH/SU parity requirements. CMS guidance provides detailed  information to help states assess their compliance with MH/SU parity  requirements. These processes vary by program type, as described  below.

Medicaid MCOs. The final rule requires either the state or the Medicaid  MCO to complete a parity analysis, depending on how Medicaid benefits  are provided. In general, CMS guidance requires states or MCOs to  assess if a plan’s MH/SU benefits are no more restrictive than medical or  surgical benefits for the following items: aggregate lifetime/annual dollar  limits, financial requirements, quantitative treatment limitations (QTL), and  non-quantitative treatment limitations (NQTL). The MCO must complete  this analysis when it provides all Medicaid benefits—both medical and  MH/SU benefits. The state must complete the parity analysis if the  benefits are provided through multiple delivery systems, such as through  multiple MCOs or the state’s fee-for-service Medicaid program, and  provide the parity analysis to CMS for review. States are also required to  make the documentation of compliance with the final rule available to the  general public.

The final rule also requires states to include contract provisions requiring  compliance with MH/SU parity requirements in all MCO and other  applicable contracts. CMS guidance encourages states to consider  including provisions in their contracts with MCOs to ensure adequate  oversight of the MCO’s parity-related monitoring and compliance  activities, such as ensuring the state can see the MCO’s parity analysis.

ABPs and CHIP. The final rule requires states to document that their  ABP and CHIP plans comply with MH/SU parity requirements in the  comprehensive state plans that describe the state’s Medicaid and CHIP  programs. CMS guidance requires that states conduct a parity analysis  demonstrating this compliance as part of the documentation the states  submit to CMS to request a change to the state plan, known as a state  plan amendment.

In certain CHIP programs and ABPs, the state does not have to complete  the full parity analysis, known as deemed compliance. A plan may be  deemed to be in compliance with MH/SU parity requirements for plan  members aged 20 and under if Early and Periodic Screening, Diagnostic,  and Treatment (EPSDT) benefits are provided to those individuals,  because EPSDT benefits include MH/SU services. CMS guidance  requires that states demonstrate that EPSDT benefits are covered by  their CHIP plans through documents such as member handbooks. (The  state or MCO would still be required to conduct a parity analysis to ensure  that plan benefits for those not eligible for EPSDT benefits satisfy parity  requirements.)

To ensure state Medicaid and CHIP benefits comply with MH/SU parity  requirements, CMS must review states’ documentation of compliance.  For Medicaid managed care, CMS must review state contracts with  managed care plans to ensure they are compliant with CMS  requirements. CMS reviews the parity provisions in MCO contracts and  the state’s parity analysis as part of the normal contract review process.  Additionally, for states in which some but not all benefits are provided by  an MCO, CMS reviews documentation of the state’s parity analysis to  ensure the full scope of services being provided complies with MH/SU  parity requirements. For ABP and CHIP, CMS staff are required to review  the state plan amendments submitted by the states and supporting  documentation for compliance with MH/SU parity requirements.

See figure 2 for a map of the parity compliance review process by  program type.

We conducted a literature review to identify information about compliance  with federal mental health/substance use disorder (MH/SU) parity  requirements by individual and employer-sponsored small and large  group health plans. We identified literature through keyword searches of  several bibliographic databases, including ProQuest, MEDLINE, Scopus,  and WorldCat. We focused our review on literature published between  January 2011 and May 2019. Of the 828 study citations we identified, we  reviewed 77 full studies; of those, we determined there were six relevant  studies. We also identified four additional studies through web searches,  interviews with stakeholders, and citations included in the literature we  reviewed. Our review included studies that contained information  collected about compliance by individual and employer-sponsored group  health plans with federal MH/SU parity requirements by assessing  compliance, comparing MH/SU plan benefits and requirements to  medical/surgical benefits, or by assessing changes in MH/SU plan  benefits over time. Our review excluded studies that focused on the  effects of federal MH/SU parity requirements on consumer utilization of  MH/SU services, consumer spending on MH/SU services, and plan  spending on MH/SU services. The 10 studies are described in more detail  below.

Berry, Kelsey N., et al. “A Tale of Two States: Do Consumers See Mental  Health Insurance Parity When Shopping on State Exchanges?”  Psychiatric Services, vol. 66, no. 6 (2015): pp. 565–567.

Methodology: The case study reviewed documents for all small  group and individual health insurance products offered on two state  health insurance exchanges between October 2013 and March 2014  and assessed compliance with observable quantitative treatment  limitations (QTL) and non-quantitative treatment limitations (NQTL).

Examples of key findings: The case study found that for 75 percent  of products offered, the financial requirements and certain NQTLs  reviewed appeared to be compliant with MH/SU parity requirements,  but compliance varied by state. On one state health insurance  exchange (with fewer products) more than half the products appeared  inconsistent with the parity requirements reviewed, particularly the  NQTLs. On the other state health insurance exchange, 11 percent of  the products contained a financial requirement that violated MH/SU  parity requirements. The case study was not able to assess all  aspects of NQTL requirements because the available documents did  not provide information about all NQTLs, such as whether or not a  specific MH/SU treatment would be considered medical necessary.

Cowell, Alexander J., et al. Changes in Individual and Small Group  Behavioral Health Coverage Following the Enactment of Parity  Requirements: Final Report. A report prepared for the United States  Department of Health and Human Services, Office of the Assistant  Secretary for Planning and Evaluation, Office of Disability, Aging and  Long-Term Care Policy. January 2017.

Methodology: The study reviewed plan documents for a sample of  individual and small group plans and assessed changes in MH/SU  and medical/surgical benefits before implementation of MH/SU parity  requirements in 2013 and after implementation in 2014.

Examples of key findings: The study found that in 2014 most plans’  financial requirements and QTLs were compliant with MH/SU parity  requirements. However, the plans included different limits on the  quantity of prescription drugs covered for medications used for  MH/SU treatments and those used for other chronic health conditions.  This difference indicated possible noncompliance with MH/SU parity  requirements for NQTLs, and the study noted that differences in  NQTLs between MH/SU and other health conditions is an issue in  need of additional study. The study stated that plan documents did not  contain all information necessary to fully assess NQTLs.

Friedman, Sarah, et al. “The Mental Health Parity and Addiction Equity  Act Evaluation Study: Impact on Mental Health Financial Requirements  among Commercial ‘Carve-In’ Plans.” Health Services Research, vol.51,  no. 1 (2018) pp.366-388.

Methodology: The study analyzed a sample of health benefit design  data from 2008 to 2013. This data on large group plans was obtained  from a managed behavioral health organization and was analyzed for  changes in cost-sharing requirements for plan members before and  after parity requirements were implemented.

Examples of key findings: The study found that there were both  increases and decreases in cost-sharing after MH/SU parity  requirements went into effect. For example, among plans that covered  both in-network and out-of-network benefits and required coinsurance  for inpatient stays, the likelihood of using coinsurance increased by 4  percentage points, and the coinsurance rate increased by .75  percentage points. However, outpatient copayments were reduced by  $3.88 among plans that offered only in-network benefits.

Goplerud, Eric. Consistency of Large Employer and Group Health Plan  Benefits with Requirements of the Paul Wellstone and Pete Domenici  Mental Health Parity and Addiction Equity Act of 2008. A report prepared  for the United States Department of Health and Human Services, Office  of the Assistant Secretary for Planning and Evaluation, Office of  Disability, Aging and Long-Term Care Policy. November 2013.

Methodology: The study summarized the results of multiple  assessments of compliance with MH/SU parity between 2009 and  2011 based on both plan data available from private databases and  the Department of Labor, and survey data and interviews with health  plan representatives.

Examples of key findings: The study found that between 2009 and  2011 large group health plans made substantial changes to their plan  designs to meet the parity requirements. By 2011, most large group  health plans had removed most financial requirements that did not  meet MH/SU parity requirements, although 20 percent still had a non- compliant copayment for outpatient services. Nearly all had eliminated  the use of separate deductibles for MH/SU treatment and  medical/surgical treatment. The study also noted that assessing  consistency with NQTLs was difficult based on document reviews.

Hodgkin, Dominic, et al. “Federal Parity and Access to Behavioral Health  Care in Private Health Plans.” Psychiatric Services, vol. 69, no. 4, (2018):  pp. 396–402.

Methodology: The study reported results of surveys of senior  executives at commercial health plans regarding changes to MH/SU  benefits over time. The surveys were conducted between September  2010 and June 2011, and again between August 2014 and April 2015.  The study did not independently verify the self-reported data from  senior executives.

Examples of key findings: The study did not find significant  noncompliance with MH/SU parity requirements. It found that fewer  plans required prior authorization for outpatient MH/SU treatment than  medical treatment. This suggests compliance with the requirement  that NQTLs applied to MH/SU treatment be no more restrictive than  those for medical/surgical treatment. The study also found that 6  percent of products used coinsurance for MH/SU treatment and  copayments for other medical care. While this is not necessarily  noncompliant, this could result in noncompliant higher cost-sharing for  MH/SU treatment than other medical care in some cases, because  coinsurance may result in higher cost-sharing than a copayment.

Horgan, Constance M., et al. “Health Plans’ Early Response to Federal  Parity Legislation for Mental Health and Addiction Services.” Psychiatric  Services, vol. 67, no. 2 (2016): pp. 162–168.

Methodology: The study reported results of surveys of senior  executives at commercial health plans regarding changes to MH/SU  benefits over time. The surveys were conducted between September  2010 and June 2011. The study did not independently verify the self- reported data from senior executives.

Examples of key findings: The study found that plans complied with  MH/SU parity requirements by lifting QTLs that only applied to MH/SU  benefits, although 4 percent of plans had QTLs that applied to mental  health treatment that did not apply to medical/surgical treatment. This  study also found that fewer plans had prior authorization requirements  for outpatient MH/SU treatment than outpatient medical treatment,  which suggests compliance with the requirement that NQTLs applied  to MH/SU treatment be no more restrictive than those for  medical/surgical treatment. The study was not able to assess if prior  authorization requirements were implemented differently between  MH/SU and medical/surgical treatment.

Huskamp, Haiden A., et al. “Coverage of Medications That Treat Opioid  Use Disorder and Opioids for Pain Management in Marketplace Plans,  2017.” Medical Care, vol.56, no 6(2018) pp.505-509.

Methodology: The study compared coverage for medications used to  treat opioid use disorder (an MH/SU benefit) and opioids used to  treatment pain management (a medical/surgical benefit) in 2017  health insurance marketplace exchange plans, using publicly  available data for a sample of 100 plans.

Examples of key findings: The study found that most plans covered  at least one of the four primary medications intended for opioid use  disorder treatment, while 100 percent of plans cover short-acting  opioid pain medications. For example, 80 percent of plans cover a  generic combination of buprenorphine and naloxone for treatment of  opioid use disorder, while 100 percent of plans cover the generic  version of Oxycodone and Fentanyl for treatment of pain disorder.  The study states that additional monitoring is needed to ensure that  plan coverage of MH/SU medications complies with MH/SU parity  requirements.

Thalmayer, Amber Gayle, et al. “The Mental Health Parity and Addiction  Equity Act Evaluation Study: Impact on Nonquantitative Treatment Limits  for Specialty Behavioral Health Care.” Health Services Research, vol. 53,  no. 6 (2018): pp. 4584–4608.

Methodology: The study analyzed a sample of health benefit design  data from 2008 to 2013. This data on large group plans was obtained  from a managed behavioral health organization and was analyzed for  changes in NQTL requirements for plan members before and after  parity requirements were implemented.

Examples of key findings: The study found plans were less likely to  require NQTLs, such as prior authorization and financial penalties for  failure to obtain prior authorization for MH/SU treatments after MH/SU  parity requirements were implemented, among plans that manage  MH/SU benefits separately from other medical benefits. However, the  study also found that plans were more likely to include a penalty for  failing to obtain prior authorization for MH/SU treatments after MH/SU  parity requirement implementation if the MH/SU benefits were  managed by the same plan that managed other health benefits. The  study was limited in that it did not assess how NQTLs were  implemented by plans and so could not determine if there were  differences in how MH/SU and medical requirements were applied.

Thalmayer, Amber Gayle, et al. “The Mental Health Parity and Addiction  Equity Act (MHPAEA) Evaluation Study: Impact on Quantitative  Treatment Limits.” Psychiatric Services, vol. 68, no. 5 (2017): pp. 435–42.

Methodology: The study analyzed a sample of health benefit design  data from 2008 to 2013. This data on large group plans was obtained  from behavioral health organizations and was analyzed for changes in  QTL requirements for plan members before and after MH/SU parity  requirements were implemented

Examples of key findings: The study found that QTLs were nearly  eliminated after MH/SU parity requirements were implemented. This  suggests that plans became compliant with parity requirements  because if a QTL does not exist it cannot be more stringent than a  medical/surgical QTL. The study noted that plans that continued to  have QTLs might be noncompliant with MH/SU parity requirements,  but did not assess that.

Center on Addiction, Uncovering Coverage Gaps II: A Review and  Comparison of Addiction Benefits in ACA Plans, (New York: March 2019).

Methodology: The study reviewed plan documents to assess  compliance with MH/SU parity requirements from a sample of 2017  benchmark plans and plans sold on health insurance exchanges.

Examples of key findings: The study identified nine benchmark  plans and 10 states that sold plans that were not compliant with  MH/SU parity requirements (where this could be identified through  plan documents). The study was able to identify non-compliant  financial requirements in three benchmark plans and non-compliant  QTLs in six benchmark plans, and found one state that sold a plan to  with a possible non-compliant QTL. The study also identified two  benchmark plans that had possibly noncompliant NQTLs, and 21  states that had either NQTL violations or indications of possible NQTL  violations that could not be fully assessed with the available  information. The study noted that plan documentation did not contain  sufficient information to fully assess compliance with MH/SU parity  requirements related to NQTLs.

Appendix III: Examples of Mental Health and Substance Use Disorder Parity-Related Guidance from HHS, DOL, and Treasury

Summary   This October 2016 publication provides an overview   of federal disclosure laws affecting private-sector,  employer-sponsored group health plans and health  insurers.

Between December 2010 and September 2019, the  three agencies issued 10 guidance documents with 58  frequently asked questions about MH/SU parity  requirements. These frequently asked questions are  designed to help people understand the law, and benefit  from it as intended through examples that illustrate the  requirements. Topics include the types of plans covered  by MH/SU parity requirements and specific examples of  how to determine if a practice or policy is permissible  under the law.

This June 2016 brochure gives a high-level overview of  MH/SU parity requirements and lists common limits  placed on MH/SU services that are subject to parity.

This April 2018 action plan released by HHS covers  recent and planned actions related to HHS, DOL, and  Treasury’s implementation of MH/SU parity  requirements. The plan, required by the 21st Century  Cures Act, includes information about a public listening  session the agencies held in July 2017.

This February 2016 publication describes MH/SU parity  requirements for people with employer-sponsored health  plans who need MH/SU treatment. It describes why  some MH/SU benefit claims are denied and how to file a  claim, the denial of a claim, and the appeals process.

Self-Compliance Tool for the Mental Health  Parity and Addiction Equity Act (MHPAEA)

DOL issued this self-compliance tool in April 2018 to help  both issuers and regulators determine if a plan or issuer  complies with MH/SU parity requirements and other  related federal health care laws.

In May 2016, DOL and HHS published this brief guide of  examples of plan provisions that—absent similar  restrictions on medical/surgical benefits—could be “red  flags” that a plan or issuer may be imposing an NQTL  that is out of compliance with MH/SU parity requirements  and should be reviewed.

Appendix IV: Comments from the Department of Labor

Appendix V: Comments from the Department of Health and Human Services

Appendix VI: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Kristi Peterson (Assistant  Director); Summar C. Corley (Analyst-in-Charge); Kerry Casey; and Eric  J. Schwab made key contributions to this report. Also contributing were  Leia Dickerson, Cynthia Khan, Laurie Pachter, Ethiene Salgado- Rodriguez, and Emily Wilson Schwark.

Before 2008, many health insurance plans provided lower benefits for mental health care than other types of medical care. Congress set parity requirements to help address this discrepancy. This means things like copayment amounts or treatment approval requirements must be equal or comparable for mental health and other care.

The Departments of Labor and Health and Human Services commonly find violations of parity requirements in reviews based on unrelated complaints or information. The agencies only base a few reviews on potential parity violations.

We recommended the agencies evaluate the effectiveness of their oversight approaches.