Junior Staff Reporter (2018 – 2019)
People with mental health conditions that go untreated—or are not properly treated—are more likely to experience unemployment, school drop-out, divorce, substance abuse, violence, incarceration, homelessness, and suicide than those without such a disorder.1 The ripple effects of these problems on families, communities, and our nation-at-large are enormous. However, there is a federal law that could help more of those affected get treatment. The law requires health insurance companies to stop the common practice of discriminating against those with mental or behavioral health disorders in the way that the companies provide benefits to those who are insured. But only 4% of Americans know the law exists.2
Consider the following two patients:
Mike is 65 with a history of smoking and an inactive lifestyle. With his high blood pressure and cholesterol, he developed emphysema and heart disease. He managed his conditions with medication, surgery, and lifestyle changes. Annually, Mike’s medical treatment costs approximately $18,0003 but will likely increase because other conditions such as diabetes and congestive heart failure commonly follow.
On the other hand, Josh is 25. He is a veteran with a history of depression and anxiety, but no other medical diagnoses. He visits a psychiatrist every six months, a counselor bi-weekly, and takes two medications to manage his conditions. Josh may need these treatments for his entire life, and their annual cost is approximately $5,000.4
If both Mike and Josh have health insurance, most Americans would probably expect Mike’s insurance to cover his medical expenses, but what about Josh’s? Do insurance companies cover the treatment of mental and behavioral health conditions like they cover physical conditions?
For a long time, the answer to both questions was likely no. Health insurers often excluded mental or behavioral disorders or significantly limited their benefits.5 But in 2008, Congress passed a law requiring patients, like Josh and Mike, to be treated with parity—with consistency or equality—and that the same standard6 be used in providing benefits for each.7 More specifically, insurers now must cover mental health, behavioral health, and substance-use disorders in a way that is similar to how insurers cover physical health conditions . This means that limiting Josh’s counseling sessions, charging higher copays, increasing his deductible, limiting access to out-of-network providers, and placing day limits on hospitalization is now illegal.8
Most Americans currently benefit from the law’s provisions.9 But what can be done if an insurance company is possibly discriminating against those with a mental or behavioral health diagnoses in the way that benefits are provided or coverage decisions are made?10 ParityTrack’s website is a great jumping off point for learning more.11 ParityTrack is a national coalition of organizations working on mental health parity implementation across the country, and its website provides step-by-step instructions on how individuals can take action if they are unsure that mental health parity laws are being followed.
There are some other options when an insurance company may have discriminatory policies against those seeking to use mental and behavioral health benefits: if the insurance is obtained through an employer, the human resources department may be able to explain the policies or know how to find out more. An individual with concerns can also contact the insurance company directly and ask questions about how mental health benefits are provided or coverage decisions made and how these actions comply with the mental health parity laws. If insurance was purchased through an insurance exchange, the applicable state’s insurance department can often assist and help a consumer identify insurance company actions that do not comply with the mental health parity laws and then recommend a course of action.
Thankfully, there continue to be national and state initiatives that are focused on improving access and outcomes for individuals diagnosed with mental health, behavioral health, and substance abuse conditions. After all, as stated by the World Health Organization, “[h]ealth is complete physical, mental and social well-being and not merely the absence of disease or infirmity.”12
1 See generally, Mental Health by the Numbers, Nat’l Alliance on Mental Illness, https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers (last visited on Nov. 25, 2018).
2 See Resources on the Mental Health Parity Law, Am. Psychol. Ass’n, (2014), https://www.apa.org/helpcenter/parity-law-resources.aspx.
3 See Anthony J. Guarascio et al., The Clinical and Economic Burden of Chronic Obstructive Pulmonary Disease in the USA, 5 ClinicoEconomics and Outcomes Res., 235–245 (2013), https://doi.org/10.2147/CEOR.S34321; Rebecca E. Scully, et al., Annual Health Care Expenditures in Individuals with Peripheral Arterial Disease, 64 J. for Vascular Surgery 1180–81 (2016), https://www.jvascsurg.org/article/S0741-5214(16)30810-2/fulltext.
4 M.D. Marciniak, et al., The Cost of Treating Anxiety: The Medical and Demographic Correlates That Impact Total Medical Costs, 21 Depression & Anxiety, 178–184 (2005), https://doi.org/10.1002/da.20074.
5 Josh’s insurance company might impose a visit limit on his counseling sessions or deny him inpatient treatment. Even if Josh’s doctor determined the counseling sessions or inpatient treatment were medically necessary, the insurance company could still deny or restrict coverage. Mike’s insurance company, on the other hand, would likely approve the surgeries, medications, and rehabilitative therapies that his doctor determined were medically necessary.
6 In general, the standard is "medically necessary" or "medical necessity" and refers to health care services that a physician, exercising prudent clinical judgment, would provide to a patient. There is not a single definition of the standard as definitions vary based on insurance provider or whether the payor is a government-run program. See generally, Michael Bahari, MD, Medical Necessity Definition in Health Insurance, VeryWell Health (last updated Dec. 5, 2018), https://www.verywellhealth.com/medical-necessity-1738748.
7 The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 29 U.S.C. § 1185a (2008). The law is commonly referred to as “MHPAEA”; see generally, The Mental Health Parity and Addiction Equity Act (MHPAEA), The Ctr. for Consumer Info. & Insur. Oversight, https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html (last visited on Jan. 17, 2019).
8 See Does Your Insurance Cover Mental Health Services? What You Need to Know About Mental Health Coverage, Am. Psychol. Ass’n, https://www.apa.org/helpcenter/parity-guide.aspx (last visited on Jan. 18, 2018).
9 For information on how Americans receive their health insurance, see Health Insurance Coverage of the Total Population, Henry J. Kaiser Fam. Found., https://www.kff.org/2fdbf6d/ (last visited on Jan. 16, 2019).
10 There are some health insurance policies governed by state law instead of federal regulations like MHPAEA. But fortunately, many states have adopted—or are working toward the adoption of—laws that mirror MHPAEA bringing similar protections to state-regulated plans. Texas’s mental health parity law went into effect in 2018. See Mental Health Parity: Know Your Rights: Factsheet, Hogg Found. for Mental Health, http://hogg.utexas.edu/project/mental-health-parity (last visited on Jan. 16, 2019); Texas Health Options, Insurance Coverage and Parity for Mental Health and Substance Use Disorder Services, Linked from Consumer Protection, Tex. Dep’t Ins. (last updated Dec. 18, 2018), http://www.texashealthoptions.com/health/mentalhealthcoverage.html.
11 ParityTrack, https://www.paritytrack.org/.
12 Constitution of the World Health Org. [WHO], July 22, 1946, 62 Stat. 2679, 14 U.N.T.S. 185, available at http://www.who.int/governance/eb/who_constitution_en.pdf