Despite federal law, insurance companies often undercover mental health care

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Michelle Romero was distraught, panicked and heartbroken as she tried to find a cure for her daughter’s depression. She continued to search for a mental health clinician within her daughter’s insurance coverage network.

But the Houston-area mother of three said she couldn’t find a psychiatrist or psychotherapist close enough to her family’s neighborhood to accept her daughter’s health insurance. In her network, a clinician was closing her practice. The other was fully booked with patients.

So each week, the family paid about $300 out of pocket for their daughter’s psychotherapy and psychiatric sessions. Romero maxed out his credit card.

Last Christmas, Romero’s daughter was hospitalized for two weeks. She was 14 years old at the time and attempted to commit suicide. It wasn’t her first try. That was when she was 10 years old and in fifth grade.

The family started the new year with a $30,000 hospital bill, only a portion of which was covered by insurance.

The Biden administration is pushing insurance companies and state regulators to expand mental health coverage. The move comes as overdose deaths are on the rise and mental health issues among youth are becoming more prevalent, disproportionately impacting communities of color. Inflation and a shortage of mental health care providers, including psychiatrists and specialists who treat adolescents, further impede access to care.

“Something needs to change,” Romero said. “There are too many people who need help. And there aren’t enough doctors.” Insurance companies “need to do better,” she says.

The federal Mental Health Parity Act and Addiction Equity Act of 2008 do not require insurance plans to provide mental health coverage, but if they do, the benefits are equivalent to coverage for other health conditions. Must. This means that deductibles, copayments, out-of-pocket limits, and prior authorizations (approval from a health insurance plan to write a particular service or prescription) should not be more stringent than for other medical care. not.

But despite the federal law, many insurance companies continue to charge higher out-of-pocket costs for mental health care or limit the frequency of mental health treatment, according to the Kennedy Forum, a nonprofit that advocates for mental health coverage equity. or imposing more restrictive pre-approval policies. A joint report submitted to Congress this year by the Departments of Labor, Health and Human Services, and Treasury vindicated these claims.

The Biden administration recently moved to do more by requiring insurers to show how their coverage policies impact patients, for example by sharing denial rates for mental health claims compared to other claims. It proposed rules that would strengthen equality under the law. Insurers must also provide data on other restrictions, such as prior authorization.

The new rules would also close loopholes that have allowed more than 200 state and local health insurance plans to opt out of the law. The administration has extended the public comment period until October 17th.

Equality means recognizing that mental health and physical health are the same.

– Kim Jones, Georgia National Alliance on Mental Illness Chapter Executive Director

Since the parity law was enacted 15 years ago, “no one can claim that we have achieved parity,” said the president of the National Association for Behavioral Health, a nonprofit representing mental health care providers, programs and facilities. Sean Coughlin, CEO, said: Coughlin said the problem is prevalent across the board, from private insurance plans to Medicaid managed care.

To increase oversight, some states have passed their own equality policies. According to the Kennedy Forum, over the past 10 years, 10 states have imposed fines totaling nearly $31 million on insurance companies for violating parity rules. And since 2018, 17 states have passed laws requiring insurance companies to certify compliance annually, according to the Council of State Governments.

“We’ve been rope-a-dope with them.” [insurers] It’s been 15 years now. And the fact is, without stricter enforcement, the plan is basically making a mockery of the law and ignoring the law,” Coughlin said. “This is why the state stepped in…because the federal parity law actually has no real effect in enforcing this.”

The Kennedy Forum reports that in most states, patients with private insurance have to go out-of-network to receive behavioral health care more often than to receive other medical care. Poor networks are a notorious problem for mental health care, exacerbated by clinician shortages. In Texas, where Romero lives, about 98% of the state’s counties are at least partially designated as mental health professional shortage areas.

The nonprofit is working with other groups, including health law advocacy groups and treatment institutes, to create a state parity policy tracking tool to help patients file parity violation complaints with state regulators. We’ve created a list of resources to help you find it.

Shortages and disastrous redemption rates

When her daughter’s asthma worsened, Maria Garcia had no trouble getting insurance to cover her pediatrician visit.

But when the sixth-grade girl began suffering from extreme anxiety, sobbing every day, cutting her hair, and trying to hurt herself, she was unable to find a psychologist who would accept her insurance and accept new patients. There wasn’t. Those who participated had a six-month waiting period.

Garcia and her husband had to pay about $200 out of pocket for each weekly therapy session, in addition to home schooling costs. Garcia had to pull her daughter out of school last year because of severe anxiety.

“I was hopeless. I felt really helpless,” Garcia said in Spanish through an interpreter. She said, “Her daughter said she wanted to commit suicide.”

After months of searching, Garcia found Community Does It, a nonprofit that provides free culturally appropriate therapy sessions to immigrant families.

However, other nonprofit organizations have not been able to continue their work. Last month, Phoenix House Texas, a drug rehabilitation program for low-income youth in Texas, closed due to unsustainable reimbursement rates.

Studies have shown that psychiatrists are less likely to participate in insurance plans because insurance companies typically reimburse mental health providers at lower rates than other health care providers. Therefore, patients are either forced to pay out-of-pocket or, if their insurance covers mental health care, file a claim and receive a partial refund, assuming they meet their annual deductible. I will receive it.

“Psychiatrists are actually paid much more to provide services out of network than they are to provide services in network. It’s natural to discourage people from doing something,” said primary doctor Jane Zhu. Care Physician and Professor at the Center for Health Systems Effectiveness at Oregon Health & Science University. “There is a lot of evidence to suggest that low participation rates, particularly among psychiatrists, are partly caused by low remuneration.”

Zhu, who researches mental health equity and access to care, said 27 states and Washington, D.C., have reported increases or plans to increase Medicaid reimbursement rates for behavioral health services from 2022 to this year. he pointed out. But in many states, interest rate changes are minimal.

Equality laws in each state are different.

The American Psychiatric Association has developed model parity laws tailored for each of the 50 states and Washington, DC, with a focus on accountability for insurance companies and state regulators.

Currently, parity policies vary widely, but some states are making progress toward tightening the rules. In Georgia, which ranks 47th in availability with 640 residents per mental health provider, last year the research and advocacy nonprofit Mental Health America reported that Began requiring “generally accepted” medical standards to be used when reviewing insurance claims, rather than unscientific proprietary medical standards. standard. In some cases, insurance plans may deny coverage, claiming that the treatment is not medically necessary.

“Equality means recognizing that mental health and physical health are the same,” said Kim Jones, executive director of the National Alliance on Mental Illness chapter of Georgia.

Like Romero and Garcia, Jones was unable to find an in-network clinician for her 9-year-old son, who suffered from panic attacks. He was on a three-month waiting list to see a psychologist an hour away and out of network.

Meanwhile, the statutory language in other states, such as Florida, poses additional hurdles.

The state ranks 46th in access to care, according to the Mental Health America report, which requires insurance plans to offer “optional coverage” for mental health conditions.

“Insurance companies or employers can offer it as part of their package or choose to offer it; they are not forced to do so,” said President and CEO of the Mental Health Association of Central Florida. CEO Marni Stahlmann explained. “You can see there’s a loophole there.”

Additionally, the law provides that plans can limit outpatient mental health treatment to a maximum of $1,000.

Florida law states, “If benefits are provided in excess of $1,000 per benefit year, their term limits, amounts, and coinsurance factors need not be the same as those generally applicable to physical conditions.” it is written like this.

Sharlette McCullough, an Orlando, Fla.-based mental health counselor who recently started accepting insurance, said one client’s plan only covered five psychotherapy sessions.

“It’s very limited,” McCullough said. “If she has one traumatic event, she may need about 13 treatments to resolve it. So what happens after she completes these five sessions? ?”

Stahlman, of the Central Florida Mental Health Association, said it would be “unprecedented” for a breast cancer patient to be “told that they could have three rounds of chemotherapy.”

After returning to Texas and undergoing multiple therapy sessions, Romero’s daughter felt better and is on the mend.

A few months ago, Romero emptied her medicine cabinet out of fear that her daughter would use it.

Instead, Romero left a message.

She cut a heart out of pale yellow construction paper for her daughter and glued it inside. There she wrote the following words:

“You are worth it. You are loved.”

This report was originally published by Stateline.

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