Understanding New Rules That Widen Mental Health Coverage

2014

Following is an excerpt from an article in the NEW YORK TIMES.com website. You may want to read the full article.

For decades reimbursement for treatment of mental health conditions was handled differently from physical illness. For example, health plans limited the number of visits covered per year and limited in-patient hospital days. In addition, reimbursement for outpatient care was often limited to 50% rather than the typical 80% applied to physical conditions. However, contrary to popular rhetoric today, all this was not discriminatory, it was simple dollars and cents because treatment of mental illness and substance abuse is not the same as other illness. This care is subject to abuse by both patient and provider, it can continue for years and it is difficult to declare a person cured. Similar limits are traditionally applied to chiropractic care, acupuncture (if covered at all), physical and speech therapy.

So while simple logic says mental health treatment should have parity reimbursement, it’s not that simple when it comes to application and cost. Mental health care and substance abuse care are important, very important, but there will be consequences in terms of higher costs for premiums and in ongoing disputes when medical necessity criteria are applied. The once or twice a week trip to the psychologist may not always pass muster.

About this “do not accept insurance” thing; that’s another red herring. What they are really saying is the provider will not accept your insurance as payment in full. Whether or not a provider accepts your insurance has nothing to do with your coverage. Generally speaking, providers that do not participate in insurance plans are either high cost (higher than their peers) or have little patient contact and thus no reason to participate; radiologists and anesthetists for example. A patient can use any provider they want, receive reimbursement from their health plan and then pay the provider. The different is an out-of-pocket cost. To suggest health plans should merely raise their reimbursements to “adequate” levels acceptable to the 50% of psychiatrists who do not accept insurance payments reflects the short-sighted thinking common today. Higher payments to providers means one thing; higher premiums for everyone. Rather we might suggest that the 50% lower their fees to the level acceptable to the other 50%. Yeah, that’s going to happen.

It’s true that finding care may be difficult because there are not sufficient providers to meet current demand let alone any increase caused by these changes, but linking that to reimbursement levels is counterproductive. You don’t need someone else paying 100% of your bill to obtain care.

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.

Understanding New Rules That Widen Mental Health Coverage – NYTimes.com.