Think You Have Adequate Insurance Coverage? Think Again.

Carol Rickard
Chair, DBSA New Jersey Grassroots Organization

Every year, millions of people go through their employer’s open enrollment period for health care insurance and are completely unaware of the danger that lies lurking in the darkness of that coverage: managed care!

As I sit to write this article, I am reminded of my introduction to managed care via a patient I cared for on the inpatient mental health unit where I had worked as a Recreation Therapist. Honestly, she comes to mind any time my thoughts move to “managed care.”

An all too common story
Linda was a mother of two young children and had made a suicide attempt using a firearm. She’d been transferred to the mental health unit after being medically stabilized. She had only been on the unit for three days, when the insurance plan’s managed care reviewer started pushing for a discharge to the hospital’s partial hospital program. The reviewer was also questioning why a family session had not yet been completed with her husband. Now mind you, the patient remained very depressed and had just had her jaw wired shut due to the gunshot wound. Ultimately the doctor refused to discharge the patient since he felt it was not safe to do so.

Every day, individuals across the country face similar experiences to Linda’s when they seek treatment for mood disorders. They are not able to get the help they need because they are being denied coverage ranging from inpatient treatment to outpatient treatment. Maybe you yourself have experienced this first-hand.

In 22 years of living with a mood disorder myself, I have been fortunate to manage it on an outpatient basis. However, I remain frightened at the thought of having to use my inpatientbenefits. I continue to believe that if more Americans knew what managed care is, or in many cases, what it is not – we wouldn’t have it!

Steps to increase access
However, there is a bright spot we can turn to for hope! Thanks to the work of many dedicated individuals, groups, and professionals, we have a federal mental parity law and the Affordable Care Act, which on a national level are beginning to address barriers to mental health care. I say beginning because there is still much work that needs to be done to truly ensure access, especially at the state level.

In New Jersey, where I live, S-2180 sponsored by Sen. Robert Gordon would provide one fix to this critical problem.

This bill would require insurers providing plans in New Jersey to cover behavioral health care services that licensed health care providers determine are medically necessary and includes both the nature (which treatment) and the duration (the length).

In other words, this bill provides the opportunity for us to provide quality care to individuals experiencing a mental health condition and to give back to the providers the ability to do their work.

It’s important to note that the bill does not limit insurance plans from conducting treatment audits – providers are still held accountable – but more importantly plan subscribers are receiving the medical care they deserve when they need it.

This is a great beginning to opening the door and creating access to care. It is also important that as the bill progresses, legislators also look at ways to limit abuses and contain costs. I could think of nothing worse than a subscriber being allowed access to care but held financially accountable for providers’ errors or abuses. This bill needs to ensure mental health care is compliant with parity laws, yet does not have stricter criteria than those for physical health.

Take Action
Now is the time to make your voice heard.  If you have a health insurance plan through the ACA or an employer and have been denied mental health care, we want to hear from you.

What was the medical necessity criteria from the plan that was used to make that decision? Don’t know? You can ask! Then share that information with us by telling your story.

Don’t have a managed care plan? Don’t let that stop you from becoming an informed citizen.

New Jersey is not alone in addressing the gaps left in mental health parity regulations; many other states are seeking legislative fixes to problems in federal mental health parity.

Read last week’s Care for Your Mind to learn what advocates in the state of Illinois are doing to ensure parity in treatment costs.

Questions

  • What steps have you or a loved one taken when denied coverage for mental health treatment by your insurance plan?
  • What would you recommend someone do if their insurance plan does not provide them with medical necessity criteria for making coverage determination?

Bio

Carol L Rickard, LCSW, TTS, has over 20 years’ experience in behavioral health including inpatient and acute partial hospitalization. She has worked with a variety of populations including women’s trauma, dual diagnosis, adolescents, geropsych, and both acute and chronic mental illness. She currently writes a weekly column for Esperanza Magazine and has written a dozen publications regarding wellness and stress management. She is member of the DBSA NJ Board of Trustees, the Hunterdon County Mental Health Board, and currently Chair of DBSA NJ GO.

What to Do When You Can’t Afford Therapy

Kimberly Morrow, LCSW

Practical advice for obtaining quality mental healthcare when money is tight

Thanks to mental health parity, many more people have access to psychotherapy than in the past. But two great barriers to treatment remain. The first is shame, as the stigma of mental illness still prevents many from seeking professional help. The second is cost, because even when people have health insurance, the expense of co-pays and high deductibles can be too much when money is tight.

For some people, the predicament of needing mental health treatment, but not being able to afford it is doubly shameful, and so they never seek the care they need.

But I’m here to tell you there are ways to obtain high-quality therapy for little or no cost, and people should never let shame get in the way of wellness. Here are some tips for talking to mental health providers about cost concerns, as well as suggestions for ways you can get free or discounted care. Continue reading

Three Challenges to Accessing Care

Ron Mandersheid, Ph.D.
Executive Director, NACBHDD

Ron Manderscheid

On the May 1 “Access to Care” post, we asked, “If you or a family member needed care today for a mental health or substance use condition, would you be able to get it?”

Access to care can help prevent, delay, and treat mood disorders, other mental conditions, and co-occurring illnesses among the 45.6 million adults and 15.6 million children and youths who experience a mental health condition.

However, in reality:

  • Fewer than 40% of adults and youths with mental health conditions—including mood disorders—ever get any mental health services
  • Fewer than 7% of adults with co-occurring mental and substance use disorders get treatment for both.

Let’s explore access challenges to the prevention, diagnosis, and treatment of behavioral health conditions.

Continue reading