Doesn’t Insurance Have to Cover Mental Health Care? What the Mental Health Parity Laws Really Mean, Part 2

readingCarol McDaid
Parity Implementation Coalition

CFYM Note: This is the second in a series of posts by Carol McDaid about mental health insurance parity and coverage rights under the Affordable Care Act (ACA). In the first post on Tuesday, Ms. McDaid advised us to learn about the law and be alert for upcoming changes. Remember, the health exchanges open for business on October 1.

Study your mental health care benefits and know your options

Whether you are purchasing insurance for the first time through one of the new health exchanges, interested in changing coverage during open enrollment, or simply frustrated with your mental health coverage, now is the time to become an informed, empowered, and vocal consumer. You need not wait for the MHPAEA final rule or the ACA’s effective date to understand how mental health parity laws can best serve your health needs. If you are engaged now, you are more likely to be prepared for any inequities or discrepancies you might encounter.

In order to understand if mental health benefits are being offered equitably, you must take a close look at your plan’s summary description. Are the co-pays, deductibles, and day- and visit-limits the same for mental and physical benefits? Examine medical management for mental health services, utilization reviews, etc. Does the plan require more restrictive prior authorization for outpatient mental health/addiction services? Are case management services, such as phone-based care, allowed? Does the plan have “fail-first” requirements that are applied more stringently for mental health medications? (Meaning, must a patient “fail” on the first-prescribed medication before coverage is allowed for the prescribed/preferred medication?)

If you do not find a satisfactory explanation of “medically necessary” mental health services, ask for one. According to the MHPAEA: “The criteria for medical necessity determinations made under a plan or health insurance coverage with respect to mental health or substance use disorder benefits must be made available by the plan administrator or health insurance issuer to any current or potential participant, beneficiary, or contracting provider upon request.”

Also, if you are considering a new plan or buying insurance through the new exchange, ask your providers if they will be participating in the plans and networks that are operating on your state’s exchange. Be sure to also ask if they will accept out-of-network patients or if the out-of-network limitations on reimbursement will discourage them from doing so. Inquire as to out-of-pocket costs to the patient if you wish to remain with an out-of-network provider—will the provider require payment upfront or the balance of the billing?

Speak up

If there is one thing to understand about the parity laws it’s that they are a beginning, not an end. The laws do not guarantee true parity will be realized, but rather provide recourse if parity is denied. While it is hugely significant that we now have two separate laws giving us rights and benefits, we must remember that the laws do not implement themselves; we bear the responsibility of obtaining parity coverage.

Federal officials have announced that they will be monitoring plans operating on the state exchanges by counting the number of complaints received about participating health plans. It is critical that we file complaints when warranted.

Is this frustrating? Of course, but we must view the current environment in terms of a civil rights struggle. Our nation’s history is filled with examples of legal civil rights being denied; but in numerous cases, persistence and continued advocacy led to the realization of those rights. We hope it won’t take 50 years, but it is going to take some time and personal effort to achieve true mental health parity. We are the new freedom fighters of the 21st century.

Instead of feeling sorry for ourselves, we must acknowledge that we are not being picked on, nor are we different from any other group struggling to realize its legal civil rights. In our case, we must ensure that the stigma and shame surrounding mental illness does not prevent us from speaking up and pursuing what is now legally and rightfully ours under these parity and health care laws.


Our next blog post will provide action steps on what to do if parity coverage is denied.

Comments:

Have you ever been denied mental health benefits from a health insurance plan?

Has shame or stigma ever prevented you from filing a complaint with your insurance company?

Will access to mental health coverage given your current circumstances improve for you with the new parity laws?

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2 comments
ElinaMark
ElinaMark

But Einsteinian levels of achievement are not all that healthcare gives us.  It gives us the ability to live lives that are free from a great deal of physical and emotional pain.  We no longer have to worry if we are going to live through the next day or even wake up the next morning—we live securely knowing that our lives are protected to such high degrees that we can experience things past generations never would have thought possible.  But again, it is not even the extremes of life that healthcare allows for, we are also able to enjoy the simple pleasures of life longer—family, friends, the ability to eat, drink, and be merry.

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