James Kennedy volunteers through his church to help young people struggling with drugs and alcohol, a cause he took up after losing his own son to addiction in 2010.
He knows firsthand the challenges of getting treatment. “Every organization requires money, and most rehab facilities are very costly,” he says. And without the ability to pay for treatment, he says, many people simply can’t get the help they need.
Historically, mental health and substance abuse services have gotten short shrift when it comes to insurance coverage. But Obamacare and another federal law passed several years ago are trying to address that.
The Mental Health Parity and Addiction Equity Act, which took effect in 2010, requires health plans that provide mental health and substance abuse services to do so in equal fashion to medical health services.
And the Affordable Care Act requires health plans to include mental health and substance abuse services as one of the 10 essential health benefits that all insurers selling plans to individuals and small businesses must now provide.
With the two laws, experts say, even people who already had health insurance will gain greater access to treatment.
“People are likely to see their benefits for mental health and substance abuse improved dramatically,” says Andrew Sperling, director of federal legislative advocacy for the National Alliance on Mental Illness. Until recently, people who had small group and individual insurance policies, for instance, “largely saw no mental health benefit at all,” he says.
Despite optimism, experts say it will take time for mental health and substance abuse coverage to gain true equality in a healthcare system that has largely treated them as an afterthought. “Just because the law changed not everything goes into effect. It’s a big ship; you can’t just turn it around overnight,” says Kita Curry, CEO of Didi Hirsch Mental Health Services in Los Angeles.
Curry and others point out existing barriers to mental health and substance abuse care, and how patients can work to overcome them.
Finding help. Mental health and substance abuse providers that accept health insurance can be difficult to find.
“Sometimes what you’ll find is that a lot of providers are not being covered in-network,” says Michael Thompson, a partner with the consulting firm PricewaterhouseCoopers. In addition, he says, many plans are cutting back on coverage for care provided outside of the network, leaving patients to pay most of the cost of care out of their own pockets.
Even when providers are listed as participating in your plan’s network, Thompson says, it’s important to confirm that they are taking new patients. “I’ve heard people describe phantom networks,” in which providers are listed with a health plan but won’t take appointments, he says.
Watch out for dubious claims of success. It can be especially challenging to find a substance abuse program that is not only covered by private insurance but also offers quality care. “Unrealistic claims are made by organizations, and there’s not much solid information,” says Thomas McLellan, chief executive of Philadelphia-based Treatment Research Institute, a nonprofit substance abuse research organization.
“Do not believe any claim of rapid care. There is no such thing as good acute care for addiction. This is a chronic illness,” he says.
McLellan’s organization is developing a website to be called Consumer Guide to Adolescent Substance Abuse Treatment. It would offer insights about how to select a quality substance abuse program.
In addition, Thompson of PricewaterhouseCoopers says most large employers offer confidential employee assistance programs, which provide free services to employees and their dependents. These offer not only short-term substance abuse or mental health counseling but also referrals to reputable treatment centers.
Be on the watch for inequities. The mental health parity law has yet to make access to care truly equitable with other medical services, experts say.
“Insurers are still operating in manners inconsistent with the law,” McLellan says.
There are a number of ways in which this manifests itself. For example, if you’re required to pay a $10 co-pay to see an internist but $40 to see a psychiatrist, that’s a violation of the law.
Also, insurers are not allowed to make it tougher to get mental health and substance abuse benefits than it is to get other kinds of medical benefits. And they can no longer single out mental health and substance abuse care for limited numbers of inpatients stays and outpatient visits.
And, once someone is hospitalized, Sperling says, it’s not uncommon for health plans to aggressively manage the inpatient care by questioning each treatment and requiring pre-authorization for every single day the patient is in the hospital.
Although not illegal on its own, he said, it may be flouting the law if this scrutiny is not equally applied to other medical care as well.
Filing fairness complaints. Even if you are sure that the mental health treatment you are getting is not on par with other medical care, it’s hard to prove. It’s not enough to say that your health plan is being unfair, Sperling says: “You have to also demonstrate they are not doing the same thing on the medical/surgical side.”
You also have the right to file an appeal if you feel your care is being unfairly denied or the benefits are harder to get than for other types of coverage. You can start by filing an internal appeal with your insurer, and if that is denied, a review by an independent third party can be requested.
Kennedy of San Clemente says he’s pleased that new laws have been put in place to improve mental health and substance abuse treatment. “The problem is now we’re talking about bureaucratic red tape.” He worries that progress cannot come quickly enough.
Resources and links:
Mental health and substance abuse treatment: Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/Treatment/
Los Angeles County Department of Mental Health: https://dmh.lacounty.gov/wps/portal/dmh
HMO appeals and general consumer assistance: California Department of Managed Care: (888) 466-2219 or healthhelp.ca.gov.
Insurance appeals: California Department of Insurance: (800) 927-HELP (4357) or https://www.insurance.ca.gov.
Employer-funded health plan appeals: U.S. Labor Department at (866) 444-3272 or https://www.askebsa.dol.gov.
Zamosky is the author of a new book, “Healthcare, Insurance, and You: The Savvy Consumer’s Guide.”