NYT: Fight Erupts Over Rules Issued for ‘Mental Health Parity’ Insurance Law

WASHINGTON — A huge fight has erupted over rules issued by the Obama administration to enforce a 2008 law that requires equal insurance coverage for the treatment of mental and physical illnesses.  The fight offers a taste of the coming battle over rules to remake the health care system under legislation pushed through Congress by President Obama.

Insurance companies and employer groups are lobbying the White House to delay and rework the rules on “mental health parity.” Insurers and many employers supported the 2008 law, but they say the rules go far beyond the intent of Congress and would cripple their cost-control techniques while raising out-of-pocket costs for some patients.

Advocates for patients generally support the rules, saying they will eliminate many forms of insurance discrimination against people with mental illness. The rules are also supported by the American Medical Association, the American Psychiatric Association and House Democrats, most notably Representative Patrick J. Kennedy of Rhode Island.

The goal of the law is to abolish discriminatory insurance practices frequently applied to coverage for the treatment of mental health disorders and substance abuse. Under the law, insurers cannot set higher co-payments and deductibles or stricter limits on mental health benefits than they set for the treatment of physical illnesses like cancer and diabetes. For decades, such disparities have been common.

Insurers and employers agree that the law prohibits them from setting numerical limits on hospital inpatient days and outpatient visits for mental health services if they do not impose such limits on other types of medical care.

But insurers say the Obama administration went overboard when it tried to regulate “nonquantitative treatment limits.” These include the techniques used by insurers to manage care, the criteria for selection of health care providers and the rates at which they are paid.

The Blue Cross and Blue Shield Association, Aetna and other insurers have urged the federal government to drop this aspect of the rules. The purpose of the law was to ensure parity in benefits for patients, not “parity in provider reimbursement,” said Justine Handelman, executive director of the Blue Cross and Blue Shield Association.

But Carol A. McDaid, a lobbyist for a coalition of mental health advocates, said, “Patients are not getting access to mental health care because many insurers are not paying enough to cover the cost of services.”

This may have three consequences for patients and their families, advocates say. Patients may be unable to find mental health experts in their health plan’s network of providers. If they go outside the network, they typically pay more. And if they cannot afford it, they may not receive treatment at all.

The American Psychiatric Association said that nonquantitative treatment limits, though less visible than limits on the number of doctor visits or hospital days, could be more insidious.

Dr. James H. Scully Jr., chief executive of the association, said some insurers had tried to “circumvent the law” by “imposing new requirements for prior authorization and the submission of treatment plans for mental health services where there were no comparable requirements on the medical-surgical side.”

Insurers strenuously object to one provision of the rules that requires them to maintain a single deductible for all medical and mental health services combined. This is a significant departure from the industry’s current practice of separate deductibles.

As a result of the change, insurers say, many mental health patients will face higher out-of-pocket costs because the combined deductible will almost surely be higher than the current one for mental health services alone.

But in a letter to the administration last week, leading House Democrats said Mr. Obama was right to prohibit separate deductibles. The law, they said, was adopted to end such inappropriate distinctions between medical and mental health care services.

A number of companies like Aetna, Magellan Health Services and ValueOptions specialize in managing mental health benefits.

In issuing the new rules, the Obama administration praised the work of such companies, saying they increased the use of mental health care while holding down costs.

But Pamela B. Greenberg, president of the Association for Behavioral Health and Wellness, which represents these companies, said the new rules would “hamstring” their ability to use the tools that have proved effective in managing mental health benefits.

In a suit over the rules, Magellan and other companies said the concept of nonquantitative limits was “boundless and ill defined” and would reach virtually every policy and procedure used to manage mental health benefits.

One premise of the law is that mental illnesses often have a biological basis and can be treated as effectively as many physical ailments. But insurers say it is impossible to use the same techniques in managing the treatment of colon cancer and schizophrenia, or heart failure and major depression.

NYT: New Rules Promise Better Mental Health Coverage

WASHINGTON — The Obama administration issued new rules on Friday that promise to improve insurance coverage of mental health care for more than 140 million people insured through their jobs.

 

Kathleen Sebelius, the secretary of health and human services, said the new rules guard against “needless or arbitrary limits.” 

In general, under the rules, employers and group health plans cannot provide less coverage for mental health care than for the treatment of physical conditions like cancer and heart disease.

Insurers cannot set higher co-payments and deductibles or stricter limits on treatment for mental illness and addiction disorders. Nor can they establish separate deductibles for mental health care and for the treatment of physical illnesses.

Read the rest of the article here

Photo by Alex Wong/Getty Images

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Share your story and raise awareness about this common, and unconscionable, practice. Let others gain from your experience and help us to improve access to treatment.  For more information about how you can submit your story to our National Bank of Eating Disorders Insurance Stories that will be shared with our associated national organizations, contact star@myneda.org

Eating Disorders and Michelle’s Law By Michael B. Snyder, J.D.

Michelle Morse was a full-time college student from New Hampshire who suffered from cancer yet continued her course load, against the advice of doctors, in order to fulfill the requirement for health care coverage as a dependent. Eating disorder patients are faced with the same dilemma, but treatment or consequences of the illness often simply prevents continued full-time studies.

Michelle’s Mother, AnnMarie first pushed the New Hampshire legislature successfully, then the U.S. Congress, to pass “Michelle’s Law,” which is effective for most healthcare plans (including self-insured plans) beginning January 1, 2010. Michelle’s law requires group health plans to provide coverage for dependents who do not meet the requirements of full-time student status because of a “medically necessary” leave of absence. The rules are simple: a dependent’s treating physician must certify to the plan that the dependent has a serious illness or injury and that the leave of absence is medically necessary, and the dependent child must have been enrolled in the group health coverage on the basis of his or her full-time student status on the date immediately preceding the leave of absence.

Work with your treatment team and insurance company to ensure that even though your child’s treatment may interfere with her or his full-time post-high-school education, it will not prevent continued healthcare coverage.

Critics Blast Insurers for Poor Coverage of Eating Disorders

More than 11 million people in the United States have eating disorders.

And because an eating disorder can be a life-threatening condition with serious medical consequences, you'd assume that most health insurances polices would cover it. But many people living with eating disorders are falling through the cracks when it comes to health insurance, because in most cases, their treatment is not adequately covered, according to the National Eating Disorders Association.

No one knows that better than the Gomez family. Emily Gomez, 17, is fighting for her life, and her parents are fighting with their insurance company to pay for her treatment.

Emily, who lives on the Outer Banks of North Carolina, is a trained singer who dreams of performing on Broadway one day. But a few months ago, instead of travelling to the Great White Way, she travelled instead to an eating disorder clinic called Timberline Knolls in a quiet suburb of Chicago, more than 1,000 miles from home.

"You know, I'd eat a normal dinner and then afterwards just go through my pantry and anything I could find I'd eat," Emily said. "Then I'd go upstairs to my bathroom and then I'd usually end up purging."

Emily now suffers from bulimia, but when she was first diagnosed with an eating disorder about three and a half years ago, she suffered from anorexia. She tried to hide it from her family, but it soon became obvious that Emily was starving herself.

"She would eat two slices of like deli ham and a couple of pieces of lettuce," recalled her mother, Leigh Gomez. "And she would eat some carrots and some cucumbers up to the 300 calorie level. And that would be it for the whole day."

Emily started passing out in school and several times she wound up in the hospital. Her doctor said something had to be done -- and fast. "Her doctor would look at me and say, 'You have got to do something and quick. … This child is extremely sick, and if you don't do something immediately, you're going to find her dead on the floor,'" Leigh Gomez said.

A team of pediatricians said outpatient care wasn't enough. They said Emily needed long-term residential treatment.

But that treatment is expensive, ranging from $750 to $1,000 a day. Because Emily was so sick, her parents assumed the treatment would be covered by their insurer, but they were wrong.

"Each time I called, they just said I'm sorry, there's nothing we can do for you,'" Leigh Gomez said.

Serious Health Consequences of Eating Disorders

The insurer said nothing could be done, because one section of the family's Blue Cross Blue Shield North Carolina policy -- written in fine print -- caps coverage for mental illnesses at $2,000. And because eating disorders are considered a mental illness by the insurer, that is all it would pay, even though Emily's treatment cost the Gomez family more than $50,000.

"It's not covering my family," Leigh Gomez said. "It is destroying my family."

Lynn Grefe, the CEO of the National Eating Disorders Association, said eating disorders are one of the leading causes of death among young people.

According to the association, 10 percent of people with anorexia nervosa die as a result of complications from the illness. Still, victims struggle for adequate insurance coverage.

"Everything is wrong with this situation," Grefe said. "I mean, you have young people. They're usually very young women, some men, who are just fighting for their lives."

Dr. Tom Insel, director of the National Institute of Mental Health, agrees that eating disorders have dangerous medical consequences.

"In the case of anorexia nervosa, you've got an illness with very severe disability [that] frequently ends up with a long-term hospitalization and high mortality" Insel said. "So for women between the ages of 15 and 24, there's about a 12-fold increase in mortality."

"Good Morning America" talked to the medical director of the Gomez's insurer, Dr. John Bradley.

He acknowledged that while the insurance company won't pay for the treatment of a child like Emily Gomez, it would cover complications that result from an eating disorder, such as a heart condition. He said that policy "absolutely" makes sense.

"This is true for depression, if someone attempts to commit suicide and they end up in the hospital ... we cover that," Bradley said.

When asked if he believes the coverage for eating disorders is inadequate, Bradley said, "I think the coverage of a lot of conditions is inadequate."

"The financial situation that this family finds themselves in is in no small part due to the cost of the care that was delivered," he said.

Hope for Daughter's 'Health and Well-Being'

Emily Gomez is back home now. Her family just submitted a new $20,000 claim for her recent stay at Timberline Knolls, which was also denied. So to pay for Emily's treatment, her family had to do something drastic.

"Well it's just really hard when you have to cash your child's college fund in because you can't get your insurance to help you," Leigh Gomez said.

The Gomez family has complained to the North Carolina Department of Insurance, saying its insurer failed to tell the family about treatment options for Emily when they were most needed. The Gomezes are now considering a lawsuit against their insurer for negligence, but Blue Cross Blue Shield of North Carolina says they handled the Gomez's claims properly and did in fact tell the family about their treatment options.

People suffering from eating disorders have won major settlements against their health insurers in court, after arguing in class action lawsuits that the disease is biologically based and that treatment should be adequately covered.

Forty-eight states have some form of parity laws, which force insurers to cover mental health disorders the same way they cover physical disorders, but only 25 of the states have laws that apply specifically to eating disorders, and the state parity laws don't affect all insurance plans, including the Gomez's.

However, a new bill recently introduced in the House of Representatives, called the FREED Act (Federal Response to End Eating Disorders), if it became law, would require insurers offering group health insurance to specifically cover eating disorders.

While the Gomez's insurer wouldn't pay their claims, after "GMA" called the treatment center Emily first stayed at -- Remuda Ranch -- the center offered free residential treatment to her if she ever needs it again.

Leigh Gomez still has hope for a healthy future for Emily.

"I hope she finds a peace of mind," she said. "That she lays down this burden that she has. That she finds health, well-being, and that she takes Broadway by storm."

On October 11, the National Eating Disorders Association will be holding its first New York City walk to raise awareness in Riverside Park.

Project HEAL is a not-for-profit organization that raises money for people suffering from eating disorders and cannot afford treatment. For more information on this organization CLICK HERE. And CLICK HERE to visit DoSomething.org to find out how you can get involved in Project HEAL.