From gun control to the opioid crisis to unacceptably long stays in emergency rooms, mental health and how it’s treated and covered is a large part of the national debate.
It is an especially important discussion for the Granite State where there is increasing concern over not only the opioid crisis but a significant gap between demand for behavioral health services—an umbrella term often used to encompass mental health care as well as treatment for substance misuse issues—and available services.
When it comes to insurance coverage for behavioral health, it can be a mixed bag. While certain laws mandate that insurance companies cover these services, those treating people in the community are still seeing gaps. State regulators are hoping new insurance rules addressing access to mental health providers may start to fix those problems.
Expanding Coverage
In the past decade, the biggest change to mental health coverage came from the implementation of the Affordable Care Act, says Tom Hutton, benefits consultant for HPM Insurance in Amherst. The ACA mandated 10 essential benefits that had to be included in all plans, no matter what carrier was offering it. The 10 included mental health and substance abuse benefits.
“This wasn’t the case before,” Hutton says. “A lot of plans before the ACA did cover mental health benefits, but it wasn’t a mandate. It was like a rider. So you could exclude it to keep your premium down. That’s not the case now.”
The ACA required insurers cover mental health and substance abuse treatment. But that coverage has control factors, such as mandating that visits be medically necessary and authorized. Those factors can change depending on the company providing the benefits, Hutton explains, adding that, “Carriers have different medical directors so authorizations can vary from one carrier to the next.”
State parity laws mandate that the patient portion of copays must be the same for mental health as it is for medical. For example, Hutton says, if a medical visit has a $20 copay, a mental health visit also must have a $20-or-less copay. Also for mental health, he adds, there’s no cap on benefits. As long as mental health or substance abuse treatment is medically necessary, the insurance company can’t put a financial limit on what it will spend.
William Brewster, vice president for NH at Harvard Pilgrim, says part of what is driving the expanded coverage is the growing acceptance that caring for and covering behavioral health is as important to overall health as covering medical conditions because they are medical conditions. Furthermore, he says, there is more recognition among doctors and insurers that those suffering from a mental health or substance abuse issue may not be able to manage their other health issues if they do not receive help.
For example, Brewster says, if a patient is suffering from an untreated mental health issue that hinders him or her from remembering to take medication for high blood pressure, caring for that person in the long run is more expensive. However, if the patient received treatment for the behavioral health problem, he or she may be better able to take care of their overall health, which in turn means fewer medical conditions and lower costs to the insurer. “It’s just what’s good for the patient,” he says.
Remaining Gaps
While all of this is arguably a step in the right direction, there are still some gaps when it comes to coverage. For example, Hutton says, one of the biggest complaints he hears is insurance companies have trouble finding providers.
“A good chunk of providers opt out of the participation of the network because the reimbursement rate that they get from an insurance company is less than the usual rates they charge their clients,” Hutton says. “So definitely the network [on the mental health side] is not as strong as on the medical side of the network.”
He explains that on a typical insurance plan, most doctors, physicians and medical providers accept most carriers in the area, but participating mental health providers are fewer and farther between. “So that’s something that they [insurance companies] can’t control,” Hutton says. “That’s up to the provider.”
Allan Moses, senior vice president and CFO of Riverbend Community Mental Health in Concord, says that while he agrees that there has been a movement to look at individuals more holistically, he does not think that the insurance industry has caught up to that concept yet.
Moses says Riverbend Community Mental Health, a nonprofit that accepts all patients regardless of ability to pay, sees several examples of this every day. For instance, he explains, Riverbend received a grant from the state a few years ago that allowed it to create a lab that does urinalysis for the substance use program. But when they do a lab test, he says, many insurers won’t cover it.
“They say, ‘Well that doesn’t fit in with a mental health center. That’s on the medical side’,” Moses says. “And we say, ‘No, it’s part of examining the patient and making sure they’re not staying on their drugs.’ And so they don’t pay for it. And that’s a whole host of insurance companies.”
In another example, Moses says, Riverbend, in partnership with the state, created a mobile crisis treatment program a couple of years ago. This program includes mental health professionals going into the community to see people before they show up at the hospital emergency room. It allows the center to admit them to one of its four inpatient beds if the person is in crisis or needs to be monitored.
“Insurances won’t pay for that,” Moses says. “So here you are trying to do the best thing not only for the patient to keep a watchful eye on them, but second, you are eliminating the costly emergency room stay and third, because the state hospital is so full, there’s no room to admit more people. So here’s a wonderful alternative, a much less expensive alternative, and insurance companies won’t pay for it.
Moses concedes that these treatments are outside traditional treatment options, but, he argues, these are best practices to address the lack of options in the state.
Moses also says the center is having trouble with insurers covering intensive outpatient programs. These are typically group programs conducted on an out-patient basis with people who have substance abuse issues or involve peer recovery support where recovering addicts offer support and guidance to those currently trying to get clean. Both of these programs are becoming more widely used and some studies show are effective, Moses says, but many insurers won’t cover them.
When that happens, he says Riverbend Community Mental Health still accepts and treats the patient, but that treatment comes out of its charity care line in the budget, which is about $3.5 million annually.
Moses says neither state or federal government programs reimburse for charity care, which means the center has to shift dollars between programs.
However, Harvard Pilgrim’s Brewster contends that insurers are forward thinking when it comes to newer forms of treatment. He says Harvard Pilgrim regularly seeks out providers offering alternative care, such as the ones Moses describes, along with such treatments as acupuncture and naturopathy. All of which, he adds, Harvard Pilgrim covers.
He says if Harvard Pilgrim members are asking for it and there is evidence to support the treatment, they will try to cover it.
For his part, Moses thinks change comes by talking about outcomes. “When we look at outcomes,” he says, “it’s just so much less expensive to see someone outside the emergency room and [provide] care in the community. It’s significantly less. So I think we have to continue to promote the outcomes that are getting people better faster, and it’s much less expensive.”
Rule Changes May Address Gap
Gaps in mental health care may be mitigated by a rules change proposed by the NH Insurance Department. Tyler Brannen, director of health economics for the department, says the department has submitted proposed rules to the Joint Legislative Committee on Administrative Rules that, once adopted, will “raise the bar for access” to behavioral health and substance use treatment.
“The delivery system capacity is less than ideal in New Hampshire,” Brannen says. “In other words, people will often have trouble getting an appointment with a behavioral health provider, and they may need to go out of network, or they may need to wait some period of time before they get access.”
There is an adequacy rule currently on the books that requires companies marketing insurance in NH to meet certain minimum standards for health-care access in order to operate in the state. For example, Brannen says, an insurance company can’t market a health plan where the only doctors you can go to are located in Oklahoma. Under the current adequacy rule, companies have to have providers in the network that people can reasonably access.
The new rules, if adopted, would only pertain to services currently being offered by insurers in the state. For example, if an insurer doesn’t offer dental coverage, it won’t be mandated to do so under the new rules. But those that do offer dental coverage will have to meet the new standards. What the rules will do, in theory, is provide better access to behavioral health services by providing an incentive for insurance companies to create a broad network of behavioral health providers rather than the narrow networks some developed. Brannen says the new rules include a number of behavioral health service categories. And most of them fall within what they are calling the core service category, which means there has to be fairly local access to those services.
One of the hopes then with the rules change is that because every insurance company will have to offer local access to these specific services, they will have to do what is necessary to contract with local providers who offer those services.
For example, the rules will help mitigate the issue Moses raises when it comes to insurers not covering blood tests at a mental health clinic. “It could potentially make it easier for the insurance company to say, ‘yes, it’s okay to get the blood test there’,” Brannen says.
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