insurance access to mental health care challenges and opportunities for transition age youth...
TRANSCRIPT
Insurance Access to Mental Health Care
Challenges and Opportunities for Transition Age Youth
Presenter:Karen Vicari JD, Project DirectorMental Health Association in California
Mental Health Association in California
www.mhac.org
Outline
Why insurance access is important to the TAY population
California’s parity law
Barriers to accessing mental health care within the private health insurance system
Tips, tools and resources
Mental Health Association in California
www.mhac.org
Why is insurance access important to TAY?
1. If you are not privately insured now, you will be soon
2. We are advocates—it is up to us to fix these problems
Mental Health Association in California
www.mhac.org
Why access to mental health care should matter to everybody:
Mental Health problems like depression may cause diabetes—People with depression are 60% more likely to develop type 2 diabetes than those without depression
Depression is a known risk factor for heart disease (people with depression are at least 3 times as likely to suffer a heart attack
Olfson et al. (2000) studied low income primary care patients—of those who rated their overall health as poor or fair, over 60% had major depressive disorder
Mental Health Association in California
www.mhac.org
Mental health and healthcare costs:
Having a chronic illness along with a mental illness can significantly increase healthcare treatment costs (and lower health outcomes) Thomas M. et al. (2005) studied 6500 adults in a
medicaid HMO. The presence of any psychiatric diagnosis more than doubled a person’s total healthcare costs
Another study looked at 3500 HMO enrollees age 50+--found that those with co-occurring mental and physical disorders had medical costs for the chronic disease up to 50% higher
Depressed patients are 3 times more likely than non-depressed patients to be noncompliant
Mental Health Association in California
www.mhac.org
California’s Mental Health Parity Law (background):
Before 2000, insurance coverage for mental health was very limited HMO coverage often included limited visits and
high co-payments PPO coverage of mental health was very
limited and based upon employers buying extra coverage
Small employers typically offered limited or no coverage
Larger employers offered better coverage
Mental Health Association in California
www.mhac.org
Background—Parity in California
AB 88 Became effective July 2000 Requires that:
(a) Every health care service plan contract issued, amended, or renewed on or after July 1, 2000, that provides hospital, medical, or surgical coverage shall provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child… under the same terms and conditions applied to other medical conditions.
Mental Health Association in California
www.mhac.org
Mental health parity Mental health benefits (for those who qualify) must be
equal to physical health benefits including: Elimination of benefit limits and elimination of higher
cost-sharing for mental health (copays, deductibles, number of covered visits must equal those of other covered healthcare services)
Insurers must cover diagnosis and medically necessary treatment of covered conditions including:
Outpatient services Inpatient hospital services Partial hospital services Prescription drugs (if the health plan covers
prescription drugs)
Mental Health Association in California
www.mhac.org
Conditions covered by parity:
Severe Mental Illnesses, including: Schizophrenia Schizoaffective Disorder Bipolar Disorder Major Depressive Disorders Panic Disorder Obsessive-Compulsive Disorder Pervasive Developmental disorder or Autism Anexoria nervosa and Bulimia nervosa Serious emotional disturbances (SED) of a child, other
than a primary substance abuse disorder or developmental disorder, that results in behavior inappropriate to the child’s age, according to expected developmental norms
Mental Health Association in California
www.mhac.org
Populations Covered by Parity
People covered by private insurance in California are covered by parity
Exceptions to parity: Does not apply to Medi-Cal
beneficiaries Does not apply to Medicare
beneficiaries Does not apply to beneficiaries of self-
insured employer plans
Mental Health Association in California
www.mhac.org
Insurance access to mental health care
If somebody has a parity diagnosis and is covered by a California health plan which is regulated by CDI or DMHC, they are entitled to mental health care which is equal to their physical health care.
If somebody has a non-parity diagnosis, they should still be able to receive treatment, at least through their primary care physician.
Mental Health Association in California
www.mhac.org
Barriers to mental health care
Although people should be able to access mental health care within private insurance, they are often unable to access appropriate care.
Mental Health Association in California
www.mhac.org
Carve-outs
In many health plans, mental health services are “carved out” to another health plan which specializes in mental health care. These mental health plans are called “specialty mental health plans”, “managed behavioral health organizations”, or “MBHO’s”.
This practice leads to unintended telephone access challenges
Mental Health Association in California
www.mhac.org
DMH Parity Report
The California Department of Mental Health issued a parity report in 2006 (Report is dated March 1, 2005)
Major findings: Burdensome authorization and reauthorization
requirements Uncertainty about the amount of treatment which is
necessary, or which should be covered Telephone access issues Difficulty of the counties to obtain reimbursement for crisis
services Lack of access to qualified and appropriate providers Difficulty in obtaining prior authorization Coordination and Continuity of care issues
Mental Health Association in California
www.mhac.org
DMHC Parity Report The California Department of Managed Healthcare issued a parity
report in 2007 Major Findings:
After-hours services are difficult to obtain Plans incorrectly deny payment for emergency room claims Plans do not include all required information in denial letters.
Plans do not: Clearly describe the criteria for medical necessity denials Clearly explain reasons for termination of services of
children who are potentially SED Consistently provide the name and phone number of the
mental health professional who made the medical necessity denial determination
Plans do not clearly present the differences between benefits for parity conditions vs. non-parity conditions
Mental Health Association in California
www.mhac.org
DMHC Parity Report (cont’d)
Major findings (cont’d): Plans do not clearly present the differences between
benefits for parity conditions vs. non-parity conditions One plan did not ensure timely access to routine mental
health appointments Plans did not ensure continuity and coordination of care or
case managementOther findings: There is confusion about the responsibility of health plans
with regard to children who receive primary services from the regional centers and the counties
Variation in coverage, availability, and quality of services offered by residential treatment centers
Shortage of providers
Mental Health Association in California
www.mhac.org
DMHC recommendations to the plans:
Eliminate emergency room payment delays Investigate consumer concerns about phantom networks Provide accountable coordination of care
Improve communication between physicians and MH providers
Develop protocols to guide interactions between medical and mental health providers and staff
Require case managers to coordinate services within the plan and outside of the plan (with schools, regional centers, etc)
Improve communication between the health plan and the carve-out
Mental Health Association in California
www.mhac.org
DMHC Parity Report Recommendations to the DMHC
Form a state agency collaborative work group Continue stakeholder forums Clarify regulations for after-hours services and
denials Enhance consumer information on the DMHC
website Continue oversight of mental health related
grievance Coordinate a consumer education program Research and report plan reimbursements to public
agencies Establish a workgroup which involves the plans
Mental Health Association in California
www.mhac.org
What does this mean for clients or consumers of mental health services?
Most people who try to access MH insurance benefits face a difficult time Initial Telephone access (Call plan, then call
carve-out, voice mail jungle, long hold times Given a list of 8-10 names to call (lists do not
often tell specialties, numbers may be old, providers not taking new patients…)
Must then return to the insurer for authorization Ongoing reauthorizations
Mental Health Association in California
www.mhac.org
Tips
Understand that people with insurance are entitled to appropriate mental health care
Understand the basics of parity
Know that many plans have employees who can help you find a provider within 24 hours
Mental Health Association in California
www.mhac.org
If you encounter a problem
Call your health plan
If you are covered by an HMO or certain PPO plans, call the HMO Help Center
Call MHAC
Mental Health Association in California
www.mhac.org
Resources
CA Office of the Patient Advocate: provides information to help HMO consumers navigate the healthcare system 1-866-HMO-8900 ; www.opa.ca.gov
HMO Help Center 1-888-HMO-2219 ; www.hmohelp.ca.gov
Mental Health Association in California 916-557-1167 ; www.mhac.org
Mental Health Association in California
www.mhac.org
What you can do:
Understand that people with mental health issues should be able to access appropriate health care
Let us know of mental health insurance access issues you face on behalf of clients
Contact us with questions and/or information
Mental Health Association in California
www.mhac.org
Contact information:
Karen Vicari, Project DirectorMental Health Association in California1127 11th Street, Suite 925Sacramento, CA 95827(916) [email protected]