Many Insurance Companies Are Refusing to Pay for Mental Health Care Despite Federal Law
According to the US Centers for Medicare & Medicaid website, the federal Mental Health Parity and Addiction Equity Act (passed and signed into law in 2008),"generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits."
In 2010, the Patient Protection and Affordable Care Act (Obamacare) added the mental health requirement to include individual health insurance policy holders.
However, a blockbuster ProPublica investigative article, aired by NPR on August 25, details how a large number of insurance providers are evading the requirement using a number of different subterfuges. The lengthy news story details how many patients are being denied care. Furthermore, many therapists and psychiatrists are leaving the commercial and non-profit insurer networks because of obstacles that include denial of care, delays in payments and impediments to communicating patient needs.
ProPublica found that,
It is often the insurers, not the therapists, that determine who can get treatment, what kind they can get and for how long. More than a dozen therapists said insurers urged them to reduce care when their patients were on the brink of harm, including suicide.
All the while, mental health providers struggled to stay in business as insurers withheld reimbursements that sometimes came months late. Some spent hours a week chasing down the meager payments, listening to hold music and sending faxes into the abyss.
The news site interviewed more than 500 providers across the nation and found the outlook for adequate provision of mental healthcare by insurance companies -- particularly for long-term maintenance -- to be generally difficult, with lives often at stake. The exodus of providers and insurance companies overruling recommendations by therapists means that those who seek mental health care may often have to pay for it out-of-pocket. For severe mental illnesses, this could cost thousands, even tens of thousands of dollars.
Persons seeking therapy are confronting "a system to squeeze them out" because their conditions can be "chronic and costly." In short, they are "bad for business."
ProPublica reported, "There are nowhere near enough available therapists in insurance networks to serve all of the people seeking care....The consequences can be devastating."
In a previous NoShameonU blog, I detailed the growing shortage of psychiatrists and identified other options for care. But many of these non-psychiatric mental health providers are now finding it untenable to wrestle with the insurance companies for authorization of care and reimbursement, among other issues. Many psychiatrists and alternative therapists are no longer affiliated with insurance companies and will only see clients for cash.
The federal laws don't define how the insurance companies determine mental health standards of care. ProPublica found that "They often create their own internal standards instead of relying on ones developed by nonprofit professional medical societies. These standards can then be used to challenge diagnoses or treatment plans."
There are less than nine states (Illinois is one of them) that have set minimum criteria for what is considered medically necessary care for mental health patients, and it is likely that there are still loopholes that the insurance companies will exploit. In a hopeful sign, California, which has passed minimum standards, fined the giant non-profit Kaiser Permanente system $50 million for violating state guidelines and required the 12.5 million member provider to invest $150 million in behavioral health care. The reality, however, is that 41 states still do not have any minimum required standards for insurance companies.
Given that numerous sources cite that approximately 50% of Americans with mental health needs do not receive care, let alone those who receive inadequate care, the ProPublica article should be a wake up call to Congress to rectify this gaping hole in the Mental Health Parity and Addiction Act.
Mark Karlin is retired, after a long career in advocating against gun violence, as a hospital executive and founder of a progressive website. He graduated from Yale University with an honors degree in English.