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.

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3 comments
lindabarnettcarlton
lindabarnettcarlton

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Nik
Nik

@turned down by to many I don' t know if you have access to a residential treatment center but, perhaps, you could get help there: http://www.artausa.org/ For example, Skyland Trail (Atlanta, GA) accepts insurance and they have a program specifically designed for young adults, ages 18-25: http://www.skylandtrail.org/youngadult.aspx (I participated in their IOP program for a few months.) Maybe it's worth looking into, even if to simply rule it out as a resource. I hope this helps.

turned down by to many
turned down by to many

i have needed help for so long now. I am 22 and have insurance but either the people that can help me dont except or insurance wont pay. ive looked in my state (NY) and out of state, but no one will except me. they say i am to severe for them. i have agreed to inpatient, but the psych ward isnt helpful at all- yes i have been there to know. if i really want help than i would need to pay out of pocket which is almost 50,000 or more just for a short time.

unfortunately i recently took a job- this for me i an excuse not to get help. i took a responsibility on myself and i wont give it up. i spent over 5 months trying to get help. because of the lack of help and insurance agreements i have given up and i most probably will do something dangerous and regretful because the of the situation. i am sure there are many more out there like me suffering and openly told there is nothing to help us out there. ive been suffering since age 5. that is 17 almost 18 years long. i wish there would be a way to really get help. but wishes are pointless and will never get me anywhere so for now i have air going in and out of my lungs, my heart beats out of rote, but the rest of me is as of now dead.