Mental Care Benefits: Don’t Overlook Them

Dealing with the health insurance system is tough enough these days even if you are feeling on top of your game. But what if you are depressed, or suffer from another mental disorder?

It’s difficult to summon the energy and determination to navigate the shoals of paperwork and telephone calls. Often, “it is hard to fight your way out of the box that seems to surround you, to say to the insurance company, ‘I want my benefits,’ ” said Patrick Cody, spokesman for the National Mental Health Assn.

That is why consumers must be particularly careful and selective in choosing a health insurance plan during the annual period known as open enrollment, when companies allow workers to make changes in their medical benefits. Whether you are getting treatment now or may need some help later, the right choice should make things run more smoothly.

Benefits for mental health and substance abuse have been squeezed in recent years, with employers inclined to be less generous about what they will pay for. While health benefits overall have been trimmed, mental health services have been hardest hit.

The average hospital stay for physical conditions dropped from 6.8 days to 5.2 days, a reduction of 23% from 1990 to 1993. During the same period, the average hospital stay for mental health conditions was slashed 47%, falling from 20.7 days to 10.9 days, according to a study by Rutgers University researchers David Mechanic and Donna McAlpine, published in the September-October issue of Health Affairs, a health policy journal. Consumers should seek a plan that offers a broad range of choice among mental health specialists: psychiatrists, psychologists, social workers and other counselors.

“A good plan will have a good selection of specialists,” said Laurel Stine of the Judge David Bazelon Center for Mental Health Law in Washington, which provides legal counsel for people with mental illness.

A big roster of specialists, however, won’t be helpful if they are too distant to be easily accessible. Look for providers with offices near your home. A reasonable standard is a five- or 10-mile drive, experts say.

“We have examples of people having to drive 20 or 30 miles to see a specialist,” said Clarke Ross, deputy executive director for public policy at the National Alliance for the Mentally Ill, a grass-roots advocacy group. Hospitals in a health plan network also should be convenient. Ross said he knows of cases in which people tried to admit themselves to hospitals but had to drive past several facilities before finding one that participated in their health plan network.

Making the right choice of health plan is vital because consumers will bear a bigger share of the financial burden. Coverage for mental health problems and substance abuse is usually much more restricted than for other conditions.

For example, the maximum number of days in the hospital is often limited to 30 per year for a mental health or substance abuse problem. Visits to a therapist or other mental health professional often are capped at 20 or 30 per year. By contrast, the same employer’s medical plan will probably offer unrestricted visits to an internist, for example.

You will probably pay more out of pocket for mental health coverage, too. The same health plan might have a 50% co-payment for a visit to a psychiatrist, requiring the patient to pay the rest, perhaps $50 or $75. The same patient could see a cardiologist, however, and pay only a $10 co-payment.

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The California Legislature has approved, and Gov. Gray Davis is expected to sign, legislation aimed at eliminating some of the disparities between basic medical coverage and mental health benefits for some specific conditions, including schizophrenia, bipolar disorder; serious depressive disorders, obsessive-compulsive disorder; panic disorder; autism; anorexia and bulimia; and serious childhood emotional disturbances. Starting in July 2000, health plans could not impose higher co-payments, deductibles or treatment duration limits for these problems than they apply to treatment of physical ailments.

If you must switch plans, and your current therapist isn’t in the new plan network, ask the plan you are considering joining whether you’d be able to continue seeing that therapist for a while, advises Christine Verdon, a spokeswoman for Magellan Behavioral Health, which runs managed-health programs for health plans and large employers. Some employers offer plans that allow you to continue seeing your former doctor or therapist for a certain number of visits--at no extra charge--for a certain time period. Other plans will permit you to see the same doctor but impose a higher co-payment.

Consumers also should ask about the diversity of providers in any plan they are considering, Verdon said. A person might feel more comfortable with a counselor of a particular race, ethnic group or gender.

Medication can be a vital tool in the treatment of mental disorders. And with pressures to control spending, there is even more emphasis on the use of drugs to reduce the number of sessions with a therapist or social worker. However, health plans are becoming more restrictive in their use of formularies, or lists of drugs covered by the plan.

Patients will have to pay a lot more for drugs that aren’t on the formulary list.

Before picking a plan, ask for a copy of the formulary to see if the drugs you or your family members are using will be available, and how much the co-payment will be. Check whether compounds in the latest generation of anti-depressant and anti-psychotic medications, called SSRIs (selective serotonin re-uptake inhibitors), are listed in the health plan formulary.

See whether the plan has been accredited by the National Committee for Quality Assurance, an independent research group that audits health plan performance. The committee looks at people being treated for depression and measures the success of plans in ensuring that patients are taking their medication after leaving the hospital. The group also examines follow-up contacts between plan doctors and patients after hospitalization.

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And the final message to consumers is: Be assertive, not ashamed. Rather than demand better coverage at work, too many people suffer in silence. Don’t be embarrassed to use benefits promised under the health plan. “The stigma of mental illness is a powerful force,” said Cody, of the Mental Health Assn. People don’t want to tell their employee benefits department about their personal problems--they don’t want to look weak and vulnerable.”