CFYM Note: Many people wonder if their health insurance will cover costs for mental health hospitalization, therapy and medication. Read this first post in a series by Carol McDaid that explains your rights concerning equal insurance benefits in relation to physical and mental disorders.
Hint: Our work isn’t over
As a person living in recovery, I know firsthand the struggles people face when seeking mental health and addiction benefits. I understand what it’s like to be sick and in desperate need of treatment, told by my employer I had to go to treatment, but denied care by an insurance company.
I was 29 and a daily drug user when my sister and employer staged an intervention. My addiction was so destructive and my despair so deep, a clinician determined that a residential addiction treatment center was the right option for me. My insurance, however, did not cover my treatment. I am fortunate—and grateful—that I had loved ones who could. The blatant discrimination and my sense of injustice led me to appeal (and appeal and appeal) my coverage denial and spurred me to become an advocate for mental health and addiction parity.
Today, wearing my dual hats of advocate and recipient of behavioral health services, I celebrate the fact that we now have the Mental Health Parity and Addiction Equity Act (MHPAEA), and that mental health parity and other rights and benefits were included in the Affordable Care Act (ACA). The new health law, which goes into effect January 1, 2014, will grant health coverage to an estimated 32 million previously uninsured Americans, including 11 million people living with a mental or substance use disorder.
Together, these two laws represent the greatest expansion of mental health coverage in a generation. Yet, these mental health and addiction laws do not, on their own, translate to equal coverage. Rather, they provide a path to parity: we—people who live with or support others with mental health conditions—must educate ourselves about the laws so we can effectively fight for our rights and benefits.
First, know your parity and health reform laws
The first step in achieving mental health parity is to hone up on the parity laws. The MHPAEA requires group health plans to provide the same level of coverage for mental health or substance use benefits as for medical/surgical benefits. The main impetus for the legislation was reducing out-of-pocket costs for people seeking mental health and addiction care.
The law applies to all employer-sponsored health plans and all Medicaid managed care plans. Employers with fewer than 50 employees are exempt and not required to provide parity coverage. Under the law, group health plans are not required to provide addiction or mental health benefits; but if benefits are offered, they must be equivalent in terms of deductibles, co-payments, limits on days of treatment, and lifetime caps.
Also, health plans cannot medically manage the mental health/addiction benefit more “stringently” than they manage the medical benefit. In other words, mental health services are subject to the same—and not more—utilization review as physical/surgical services. If a plan does not require prior approval every few visits for a physical/surgical service, for example, it cannot require prior approval for every few visits for mental health treatment. The ACA goes even further and requires all individual and small group plans offering benefits in and outside the newly created state health exchanges to provide mental health coverage. In addition, under the ACA, all plans offering benefits through the health exchanges—regardless of size—are subject to MHPAEA, and therefore must provide mental health benefits at parity with medical/surgical benefits.
Next, understand what’s on the horizon
One of the challenges in implementing the MHPAEA has been identifying which services in physical health are comparable to services in mental health, so that the same level of coverage can be provided for both. In 2010, the Obama administration released the interim final rule for the MHPAEA. The rule, effective in 2011, clarified how parity between mental health and physical health services will be determined. For instance, the rule established that caps on out-of-pocket expenses must be the same for both types of care.
Sometime in the next month or so, the Obama administration will release the final rule for the implementation of MHPAEA. We hope this will clarify some of the grayer areas of the law, including how plans can make apples-to-oranges comparisons, mental health to medical benefits. For example, it will provide some clarity in whether the scope and continuum of mental health services must be provided at parity with medical/surgical benefits.
Beginning October 1, Americans can start enrolling in the new health insurance exchanges. October also marks “open enrollment” for those with existing employer-sponsored health coverage. This is a period of time when people are allowed to make changes to their insurance coverage. It is an opportunity to evaluate options available through the plan and change your coverage level.
With the soon-to-be-released parity final rule, the opening of the health exchanges, and the start of open enrollment, the next few months present a critical time for anyone interested in mental health coverage and parity.
Read the Care For Your Mind September 19 post for more action items from Carol McDaid
- Can you describe an experience where you have been able to receive unlimited doctor’s visit for a chronic medical condition?
- Did your insurance company ever attempt to deny your continued receipt of those services?
- What are some examples of the physical equivalent of a psychiatric hospitalization?