Helping families, providers and facilities obtain medically necessary mental health and autism treatments through health insurance. |
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The Promise of Mental Health Parity, 13 years later
Part I: Network Adequacy
The Federal Mental Health Parity and Addiction Act was signed into law thirteen years ago. The key promise in the act is that ”the financial requirements and treatment limitations for mental health or substance use be no more restrictive than the predominant financial requirements or treatment limitations applied to substantially all medical and surgical benefits covered by the plan.” Also, that “there be no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.”
For the most part, benefit manuals have been rewritten to reflect parity in financial requirements, such as deductibles, co-payments, co-insurance and out-of-pocket maximums. Thank you, but that just is not enough!!
The reality is that consumers frequently have to go out of network to find skilled providers and facilities with current availability to competently treat their mental health conditions. A recent Milliman Research Report found that consumers were 5.2 times more likely to use an out-of-network inpatient facility for mental health treatment than for medical or surgical conditions. The rates for going out-of-network for outpatient mental health facilities was 5.7 times more likely than the medical/surgical analog, and the rate for office visits was 5.0 times more likely than for medical/surgical visits. Rates are even higher for those with substance use disorder (SUD). These rates were studied over a five-year period and went up significantly in all three categories during the course of the study. Yet, average reimbursement rates were nearly 24% lower for mental health compared with payments for primary care. In 11 states the reimbursement rates were more than 50% lower.
Mental health providers are often unwilling to work with payors, in part because the rates are so low and in part because the time involved in getting approvals and recovering money that is owed can be onerous.
This frequently leaves health plans with inadequate mental health networks. Many states have network adequacy laws, requiring that consumers not have to travel more than 30 miles from their homes for outpatient mental health treatment, and 60-100 miles for residential. When families call us seeking mental health treatments, we often encourage them to explore what is available within the network, call down the list, call the health plan back if there are no appropriate treatments available, and request a single case agreement with an out of network provider (if one is available). While it may result in several hours of work, the cost savings of using in-vs. out-of-network benefits can be substantial.
Market forces SHOULD prevail, plans should want to build their mental health networks and pay mental health providers in parity so that they will be motivated to work with them. But we’re not seeing that. Why not, you may ask? Because at both the state and federal level, there simply is not enough regulation.
The interesting thing about good regulation is that if you fine the health plans enough, it will incentivize them into action, and those fines will cover the costs of the regulators who enforce them. When the amount of the fine is less than the payment avoided, there is no incentive for the plan to fix their system.
While much of enforcement is complaint driven, thanks to the Consolidated Appropriations Act of 2021, regulators now have the authority to request comparative parity analyses from health plans, asking them to describe how their practices conform with mental health parity. Consumers also have this right – this form can be useful if you are having difficulty obtaining services or information from your plan. This guide, put out by SAMHSA, also may be helpful to consumers in understanding their rights. What will happen if plans fail to provide documentation or provide adequate explanations? How will this translate into better regulation at both the federal and state level? Will it contribute to plans developing more robust networks? Will it result in prompt payment of necessary mental health services? All of these questions remain to be answered, but I’ll take it as a small step in the right direction for now.
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Events
Thursday, May 27, 2021, 10 am - 12 pm PST, 1-3 EST
Karen Fessel will be speaking on Hospitalization and Residential Treatment for Severe ASD: Are We Still in the Dark Ages? Other speakers include:
Lori Unumb and Judith Ursitti, both with The Council of Autism Service Providers (CASP) and Arzu Forough, with Washington Autism Alliance.
Registration is free. Register here. The event will be recorded.
Podcast: American Health Law Association's Behavioral Health Task Force: Payment Parity for Behavioral Health, Part 2: Perspectives from a Payer, Provider, and Parent Advocate
Gregory Moore of Dickinson Wright PLLC, moderates a discusssion with Deepti Loharikar, Association for Behavioral Health and Wellness, Karen Fessel, Mental Health and Autism Insurance Project, and Alec Green and David Green, Sanford House, about behavioral health payment parity and other issues from the payer, provider, and parent advocate perspectives. Listen to this lively discussion here.
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Case Wins
$41,000 Recovered for Residential Treatment
We helped the family of a 22 year-old woman with complex trauma obtain a single case agreement and recover $41,000 of a $60,000 claim for an 8 week stay at a trauma specific residential treatment center in Florida.
"MHAIP was a tremendous help in both advising us on how to approach this and what we should expect and ask for. When the plan was dilly-dallying on approving our request, a letter from MHAIP got things moving very quickly. Had they not been working with us, there would have been a lot more withholding of information and funds. Their knowledge of the system and the legal obligations of the insurance company were critical in helping us to get our daughter into the facility and getting it paid for. " Colleen, Philadelphia PA.
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Speech Therapy and Augmentative Alternative Communication Device Denials Overturned
MHAIP succeeded in getting twice-weekly speech therapy sessions reinstated for a five-year-old girl with autism. When the pandemic shelter in place commenced, this young girl’s therapies and autism spectrum kindergarten classes went 100% online. She struggled with communicating through her computer, staying focused and remaining on task. Three months into the pandemic Kaiser terminated her speech therapy sessions due to a “failure to progress in treatment.” Kaiser also would not approve an augmentative alternative communication device recommended by the speech therapist. By analyzing her therapy goals and assessments, MHAIP showed that she was making progress. We also determined that Kaiser did not apply the correct Medi-Cal standard in assessing her progress. The Department of Managed Healthcare overturned the denial and instructed L.A. Healthcare to provide the twice-weekly speech therapy sessions. Kaiser subsequently contacted the family about an appointment for an augmentative alternative communication device.
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Pressure from MHAIP Forces Blue Shield of California to Reinstate ABA Therapy Hours to Previous Level
When Blue Shield of California reduced weekly ABA therapy from 25 hours per week to 15 hours per week for a 15-year-old young man diagnosed with autism spectrum disorder and intermittent explosive disorder, the result was a serious and dangerous increase in maladaptive behaviors and a regression in his progress. Blue Shield of California claimed the young man was making progress, when he was actually regressing and was physically acting out, destroying property and assaulting his parent and therapists. Blue Shield of California provided vague and medically incorrect reasons for reducing the number of ABA therapy numbers, including wrongly claiming that ABA therapy was not effective for adolescents and that a certain number of ABA therapy hours was “excessive.” Further, Blue Shield's denial violated the California Autism Mandate Standard for Assessment. MHAIP submitted a request for an Independent External Review of the reduction of the hours, but Blue Shield responded by reinstating the hours to 25 hours per week before it was reviewed by the External Reviewing company.
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Coverage for Balance of RTC Care Authorized by King County, WA
In October of 2020, we reported here that MHAIP helped a client win partial coverage in an External Review of 28 days of treatment at an RTC. At the same time, MHAIP advised the client to appeal denial of her son's care to her plan sponsor. We are happy to report now that the client learned in late December that King County issued an administrative approval for the balance of the denied dates.
It has taken constant pressure from MHAIP to ensure that the client actually gets paid. There have been delays in every step of the process: claims processing, claims acknowledged as approved, an incorrect number of days to be reimbursed, slow payment approval and slow payment to the facility. The client was finally reimbursed in full in March.
"It was a relief to turn all the details of getting the insurance to pay our claims over to the expertise of MHAIP, as the task was consuming my energy and peace of mind." Cindy G
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Residential Treatment and PHP Coverage for 16 Year-Old Young Man
MHAIP got 42 days of coverage for residential treatment and 314 day of partial hospital coverage for a 16 year old young man from Seattle with depression, anxiety, ODD and cannibis use. The family had coverage with Premera at the out-of network level of care. The family recovered over $60,000 of reimbursements.
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Over $42,000 Recovered for Family in MD with Assistance From Maryland Insurance Administration
A 16 year-old resident of Maryland struggling with Major Depressive Disorder, Anxiety and OCD bravely sought treatment with a wilderness program. Despite an attempt to pre-authorize the medically necessary services, all 77 days were denied by CareFirst BlueCross Blue Shield based on lack of pre-authorization. MHAIP argued in appeal that CareFirst had effectively blocked the attempted pre-authorization by telling the facility that wilderness was not a covered benefit, and, to deny based on an unwritten exclusion for wilderness therapy is considered a hidden exclusion which is a violation of the federal Mental Health Parity and Addiction Equity Act. After losing on appeal, MHAIP sought help with the Maryland Insurance Administration (MIA) and submitted a complaint. Thanks to the relentless and thorough efforts of the MIA Investigator, the denial was overturned and CareFirst was ordered to reimburse the family for the entire expense of $42,510.
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Coverage for Two Months of Residential Treatment Won in External Appeal
We won two additional months of residential treatment level of care for a 15-year-old girl with depression, anxiety, PTSD, substance abuse and borderline personality disorder after her insurance company continually denied she met the continued stay criteria. We took our appeal to the “external appeal” level and won, which compels the insurance company to reimburse the parents for residential treatment for that period of time.
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Continuation of the Feda Fund |
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As an organization, we lost Feda Almaliti and her son, Mohammed to a tragic house fire. Feda was a valued and loved board member whose vision had guided us through many years. We established the “Feda Fund” with donations from many who were touched by all she had given of herself to our community. We are providing grants to a limited number of clients. Writing appeals and external review requests, and providing direct advocacy services takes a significant amount of time from highly trained advocates. It is an expensive process.
We will need your continued financial support to be able to keep this wonderful program, and Feda and Mu’s memories alive. Thank you for your active support.
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Executive Director and Founder |
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Use the drop-down to choose "Feda Fund" |
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Donate Now to our General Fund
The General Fund supplements our sliding scale program, pays for educational seminars and workshops for families and professionals, and allows us to provide free advice to families needing help with insurance.
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Thank You to All Who Have Given Generously |
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Bronte Abraham
Amazon Smile Foundation
American Online Giving Foundation
Diana Avantes
David Ben-Arie
Kelly Bermingham
Jess Block
Bright Funds
Beth Boullianne
Eileen Boussina
Michael Brier
Alan Brier
Mercedes Chocek
Fiona Coffee
Escher Family Fund
Karen Fessel and Jeffrey Kirschenbaum
Kent Grelling
Tracy Guiou
Abdurahman Idris
Sara Jocham
Stephanie Katleman
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Laurie Kazenoff
Russell Kirschenbaum
Cynthia Lejeune
Office of Personnel Management, Combined Federal Campaign
Matt Panuawat
John Park
Pay Pal Giving Fund
Mirella Peterson
Marla Seedle Root
Barbara Schulman
Stanley Sindelar
Hunter and Marcy Coen Smith
Christa Stevens
Amy Tessler
Judith Ursitti
Lisa Valerio
Amy Weinstock
Jeffrey and Sherry Williams
Marilyn Williams
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