Insurance Access to Mental Health Care

1. Insurance Access to Mental Health Care Challenges and Opportunities for Transition Age Youth Presenter: Karen Vicari JD, Project Director Mental Health Association in California

2. 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

3. Why is insurance access important to TAY? • If you are not privately insured now, you will be soon • We are advocates—it is up to us to fix these problems

4. 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

5. 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

6. 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

7. 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.

8. 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)

9. 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

10. 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

11. 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.

12. 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.

13. 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

14. 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

15. 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 betweenbenefits for parity conditions vs. non-parity conditions

16. 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 management Other 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Contact information: Karen Vicari, Project Director Mental Health Association in California 1127 11th Street, Suite 925 Sacramento, CA 95827 (916) 557-1167 kvicari@mhac.org www.mhac.org