Understanding New Rules That Widen Mental Health Coverage
Long-awaited improvements in insurance coverage for mental conditions and addictions are expected to become more widely available this year as a result of two major steps that the Obama administration has taken.
The president’s signature Affordable Care Act includes mental health care and substance abuse treatment among its 10 “essential” benefits, which means plans sold on the public health care exchanges must include coverage.
In addition, rules to fully carry out an older law — the Mental Health Parity and Addiction Equity Act of 2008 — were issued in November, after a long delay. The parity law says that when health insurance plans provide coverage for mental ailments, it must be comparable to coverage for physical ailments. For instance, plans cannot set higher deductibles or charge higher co-payments for mental health visits than for medical visits, and cannot set more restrictive limits on the number of visits allowed.
The new parity rules apply to most health plans and became effective beginning July 1, although many plans will not have to comply until January of next year.
While many plans are already complying with certain aspects of parity, the final rules fill in gaps about how the law must be applied, advocates say. For instance, plans cannot limit mental health care to a specific geographic region, if they do not do so for physical illnesses. And the rules clarify that the law also applies to “intermediate” treatment options for mental health and addiction disorders, like residential treatment or intensive outpatient therapy.
Insurance plans also must be consistent when deciding whether treatment for physical or mental ailments is medically necessary, and they cannot make getting prior-approval for inpatient mental health treatment more difficult than that for admission to an acute care hospital, said Andrew Sperling, director of federal legislative advocacy at the National Alliance on Mental Illness. They must also let patients and doctors know what criteria are used to make those decisions, which can be helpful if coverage is denied and a patient wants to file an appeal.
In the past, when health plans offered mental health coverage, it was often at less generous levels than benefits for medical care, said Debbie Plotnick, senior director of state policy at Mental Health America, an advocacy group. “All these discriminatory practices kept people from getting mental health care, and they are no longer allowed under the parity law,” she said.
Still, consumers will have to take time to understand details of their health coverage, so they can raise questions if they think their plans do not follow the rules, said Carol McDaid, a lobbyist specializing in behavioral health issues. “Consumers have to know what their rights and benefits are,” she said.
Expanding insurance coverage does not necessarily mean everyone who needs care can easily find it. Many office-based psychiatrists, for instance, do not accept insurance, partly because reimbursement for services has been inadequate. A study published in December in the journal JAMA Psychiatry found that only about half of psychiatrists accept private insurance.
It’s also still unclear just how the parity rules apply to some coverage under Medicaid, the federal-state health plan for low-income people; further guidance is expected on that, advocates say. (The parity law does not apply to Medicare, the federal health plan for people 65 and older. But payment for psychological services under Medicare is now comparable to that for medical services, under the requirements of a different law.)
Here are some questions to consider:
■ What should I look for when evaluating a plan’s mental-health benefits?
Advocates say one of the most important features to consider is a plan’s network of mental health professionals. Check to see if providers are in your area; otherwise, you may pay higher fees for seeing an out-of-network therapist.
■ What if my health plan is unfairly restricting mental health benefits, or has denied my claim?
The Parity Implementation Coalition, formed to promote compliance with the law, offers a tool kit to help you file an appeal, at parityispersonal.org. Steps beyond an appeal with your insurer depend on what type of plan you have. For instance, private companies that buy insurance for their employees, rather than paying claims directly, are considered “insured” and generally are regulated by state insurance departments. But if your company is “self-funded” and pays health claims directly, your appeal most likely would be handled by the federal Labor Department. Coverage through state or local governments, meanwhile, may be regulated by the federal Health and Human Services Department. If you don’t know what kind of plan you have, call your plan administrator and ask.
■ What if I can’t find a therapist who accepts my insurance?
Contact your county behavioral health department, which coordinates mental health care and can help you find affordable treatment. The federal Substance Abuse and Mental Health Services Administration also offers a service locater, samhsa.gov/treatment/index.aspx on its website.
— From the New York Times by Ann Carrns