Law requires equal access to mental-health and drug-abuse treatment, but is not always obeyed; Ky. says it’s working on issue

By Melissa Patrick
Kentucky Health News

By law, mental health benefits must be offered equally to medical and surgical benefits if the plan offers them, but this isn’t always the case.

Not only does a 2008 federal law require most employer-sponsored plans to provide equal access to mental health benefits, but that parity was expanded and strengthened in 2010 by the Patient Protection and Affordable Care Act. Twenty-three states, including Kentucky since 2000, require some level of parity.

Common requirements of these laws prohibit insurers from charging higher co-payments and deductibles for mental-health services; require insurers to pay for mental-health treatment in the same scope and duration as medical treatments; ban insurers from requiring additional authorizations for mental-health services; and says they must offer an equal number of mental-health providers and approved drugs.

While insurers typically keep track of the copayment and deductible requirements, they struggle with keeping track of the compliance requirements related to actual delivery of medical services, Michael Ollove reports for Stateline.

The spokeswoman for the Kentucky Department of Insurance, Ronda Sloan, said in an e-mail that Kentucky is very diligent about parity requirements. “Kentucky insurance companies must cover mental-health treatment like other covered services,” she wrote. “We review both provider networks and drug formularies for compliance and (make sure) both meet the requirements of the ACA.”

A recent report by the National Alliance on Mental Illness found that this isn’t always the case. Nearly one-third of those surveyed were denied authorization for mental health and substance abuse treatment, with this rate nearly twice as high for those on ACA plans.

It also found other barriers to care including the number of mental health providers in health insurance plan networks; more than half of the health plans analyzed covered less than 50 percent of anti-psychotic medications; high out-of-pocket costs for prescription drugs; high co-pays, deductible and co-insurance rates; and a lack of information about mental health coverage to consumers to help them make informed decisions in choosing their health plans.

The survey was conducted by Avalere Health and is based on a survey of 2,720 individuals with mental illness or with someone in their family with mental illness and an analysis of 84 insurance plan drug formularies in 15 states.

Sloan said that in Kentucky, “Work is being done on many fronts to increase access and progress is being made to address some of the access issues.”

She said Kentucky monitors provider networks to make sure they are meeting their minimum requirements. She also said that a recent law passed by the 2015 General Assembly, which created three levels of drug and alcohol counselors with varying degrees of  certification, will have a “positive impact” on access to treatment.

Gwenda Bond, spokeswoman for the state Cabinet for Health and Family Services, said in an e-mail, “We also opened the provider network for behavioral-health services in early 2014 to a range of private providers of such services, increasing the number of options available for members, who previously could only receive treatment through the community mental health centers.”

One of the main obstacles for consumers and providers is that it is not clear what criteria insurance companies and managed-care Medicaid organizations use to determine medical necessity for mental-health and substance-abuse care, and aren’t transparent with this information.

“Without that information,” Ollove wrotes, “it is difficult for regulators and consumers to determine whether the denial of coverage is warranted.” 

Ollove also notes other problems include the federal governments delay in creating regulation guidelines, the challenges states and the federal government have had in simply implementing the ACA, let alone regulating parity and the stigma that is still associated with mental illness and addictions that make regulators not want to get involved.

Two states, New York and California, are leading the way in enforcing parity rules, Patrick Kennedy, a former Democratic congressman from Rhode Island, told Ollove, saying that they were the “only states that consistently enforce mental health parity.”

Sloan took issue with that, saying, “We believe Kentucky consistently enforces the rules related to mental health and substance abuse parity.” 

Kentuckians who believe they have been improperly denied mental-health and substance-abuse care should contact the Department of Insurance.

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