Access to and affordability of mental health services is dismal in this country. In continuing the discussion about affordability of health care in America, below I discuss issues of access specifically in regards to mental health care in light of the Mental Health Parity Act (MHPA) and the Affordable Care Act (ACA). While these laws have made some small progress to improving access to of mental health care in the private insurance realm, many still are unable to receive the treatment they need. In truth, I do not think w will see a meaningful increase in access mental health care because even in light of these policy changes, it remains unaffordable.
Changes to Cost:
Before the MHPA of 2008, private insurance could set different coverage limits on mental health services. The MHPA changed this, requiring insurers to cover mental health like medical/surgical benefits. But it still allows an employer to restrict the extent and scope of this coverage. I think most people assume this parity means mental health services that are covered are as extensive as medical/surgical coverage, but really it means that the copays, coinsurance, and deductibles, and lifetime & annual limits for services are the same.
By 2014, the Affordable Care Act prohibits insurance plans from imposing annual dollar limits on the amount of coverage an individual may receive – this would apply to both medical/surgical coverage and mental health coverage because of parity. Before, an insurance plan could stop paying on your benefits after your total medical costs were over $500,000 that year, if that were the limit they chose. This includes all medical, surgical and mental health benefits. This is a problem if you have a serious mental illness and are hospitalized several times or need intensive inpatient treatment (which they may or may not cover) and you need prescriptions for your mental health or have comorbid/coexisting conditions like type 2 diabetes or cancer. That limit could be reached fairly easily, leaving an individual to pay the rest of the expenses out of pocket. But as of September 1st last year, they must cover at least up to $1.25 million. Next year that will be raised to $2 million. And by January 1, 2014 they cannot have any limits. So no matter what care you need, medical, surgical, mental health, you will only pay your premium, copays, deductibles, and coinsurance amounts.
Expanding Services Covered:
The services covered under an insurance plan – i.e. which providers you can see, what diagnoses/illnesses are covered, how many visits they’ll pay for – still varies by insurance policy. Each state has its own rules on what insurance plans must offer. Thus, unless codified, insurance policies do not have to offer coverage for mental health services that they do not want to cover. In Texas, the legislature has debated whether insurance plans must cover treatment for eating disorders. Currently, insurers do not have to consider that a “serious mental illness” and thus do not have to offer coverage for an insured seeking treatment for that condition. Thus, even if you have some mental health coverage, it may not treat the conditions for which you need help.
Under the ACA, individual and small group insurance plans must cover certain “essential health benefits” (EHBs). These are meant to be a comprehensive set of services and include “mental health and substance use disorder services, including behavioural health treatment” coverage. However, EHBs are not yet defined and there is a lot of controversy as the rules and regulations are developed. As of now, the Department of Health and Human Services is primarily leaving it up to the states to decide what counts as an EHB. So while mental health must be covered in small group or individual plans, at what level or which conditions depends on where you live. However, mental health coverage for these plans should be similar to large group insurance plans which will be used as benchmarks.
Regardless, even if insurance does cover mental health illnesses that a particular individual person suffers from, many mental health providers will not accept private health insurance, rendering coverage fairly meaningless. Certainly, insurers have to have to be contracted with therapists in your area. They have to provide “network adequacy” meaning that you should be able to find a mental health provider that will take your insurance and they can give you a list of those providers. But because few providers take insurance, the ones that will take your insurance may be backed up, their schedules full. Now, an insured can request a “special exception” or “in-network exception,” but this is a bit complicated and frustrating at times.
Removing Pre-existing Condition Exclusions:
Currently, insurers can refuse coverage for pre-existing conditions, including mental health illness. They can deny coverage if the condition was documented or if a reasonable person would have known they had an illness. This created an interesting situation for individuals filling out intake forms for their health care providers or what health care providers might put in their notes in terms of what documentation exists to show you knew you had a pre-existing condition.
Many group plans do not have pre-existing condition exclusions (partly because the risk is spread out among a larger population). But when someone loses a job or leaves for a smaller employer or self-employment, they may lose that coverage (if they can afford it, and the employer keeps providing insurance, the former employee can stay on the insurance plan by paying the premium out of pocket, which gives them 18 more months of coverage).
When losing health insurance, the insurance company must send you a certificate of creditable coverage. Creditable coverage generally means that you were insured within the previous 60 days. With the certificate, you may avoid limits on pre-existing conditions when you apply for insurance again. But creditable coverage only lasts those 60 days. So if you applied for insurance on day 61, insurance companies can exclude your pre-existing conditions.
As part of the ACA, by 2014 an insurance plan cannot consider refuse to cover pre-existing conditions including mental health conditions. Already, under the ACA, insurers cannot limit or deny coverage for pre-existing conditions for children. This will be expanded to adults in the next few years. Additionally, in 2014, insurance plans cannot charge higher premiums, put lifetime limits on coverage for key benefits, or deny coverage because of a mistake on an application.
Until 2014, individuals with pre-existing conditions who cannot afford insurance or whose employer does not provide insurance can get coverage through their state’s Pre-Existing Condition Insurance Plan (PCIP). Some states also have high risk pools, but PCIP is much more affordable. The drawback being that you have to have no insurance coverage at all for 6 months prior to applying for PCIP and for high risk pools as well. PCIP will only last until 2014 when insurance plans can no longer deny or limit coverage for pre-existing exclusions.
Do current policies increase access to mental health care?
Theoretically, considering mental health parity and the elimination of annual dollar limits on coverage, coverage for EHPs, and insurance plans no longer restricting coverage of pre-existing conditions, yes. But this won’t happen for two more years really. And ACA does not change what exactly insurance plans will cover – other than the obscure EHBs. Nor does the ACA require mental health care providers to accept health insurance, so finding a therapist who treats your condition (if it is covered) is contracted with your insurer can be a huge barrier to access. The ACA does not put limits on premiums, co-pays, co-insurance, or deductibles. Premium increases (the amount they change from year to year) must be reviewed and are limited. But premiums can still be really high. More “affordable” plans, mean higher deductibles, co-pays, and co-insurance. And these monetary barriers do not just effect your ability to see a medical or mental health care provider but also your ability to afford medications as prescribed by those providers. In addition, we must consider whether there are even enough medical or mental health care providers to even address and treat mental health conditions. So even if the ACA provides slightly better access, that access can be limited if there aren’t enough providers to help everyone.
Though policy changes are making small positive changes in addressing mental health care in America, is there really increased access to mental health care? No.