As anyone who has ever sought help for addiction, depression or any other mental illness knows, insurance coverage is often skimpier than for a physical malady. Plans typically limit the number of therapy visits they'll pay for, and they may also impose a separate deductible for mental health and substance abuse services and require higher out-of-pocket contributions from patients.
Two federal laws that provide better insurance coverage for more people with mental health and substance abuse conditions are just beginning to take effect, and advocates describe the changes as a huge win for consumers that will greatly improve treatment.
Under the Mental Health Parity and Addiction Treatment Act, which took effect this year, the mental health and substance abuse benefits that a health plan provides have to be just as generous as its coverage for medical and surgical treatments. The law does away with different co-payments, deductibles and visit restrictions.
"These financial equalizers will be very helpful to families that have not been able to access care before," says Katherine Nordal, executive director for professional practice at the American Psychological Association.
Coverage isn't mandated
Plans are not required to provide mental health or substance abuse coverage, however, and they can also determine that they will not cover specific disorders.
Some companies made the changes starting last January, but the regulations on parity went into effect July 1, so in most plans the changes become effective when they renew their coverage after that date, said Elaine Alfano, deputy policy director at the Bazelon Center for Mental Health Law in Washington.
The parity law — which was championed by former Sen. Pete Domenici, R-N.M., and the late Sen. Paul Wellstone, D-Minn. — doesn't apply to plans at companies with 50 or fewer employees or to individual health insurance policies. The new health-care overhaul law, however, will eventually pick up the slack. Under the law, health plans sold through the state-based insurance exchanges that will begin offering coverage in 2014 must include mental health and addiction benefits, and the benefits must be on a par with a plan's medical benefits. The exchanges will be open to individuals and to small businesses with 50 or fewer employees.
Advocates say they are pleased on the whole with the new laws. But they are watching closely to see whether plans try to erect roadblocks to treatment by claiming it's not medically necessary, for example, or requiring that someone get preapproved before receiving services, says Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness.
Texas family sees new help
For the Bryan family of San Antonio, the new laws are already making a difference. Kevin Bryan, 17, has had bipolar disorder since he was a child. But as he went through adolescence, Kevin became increasingly paranoid and out of touch with reality, says his mother, Chris. About three years ago clinicians determined he suffered from schizoaffective disorder, a diagnosis that led to a change in his medication and a doubling of his outpatient therapy visits to twice a week.
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Unfortunately, the health plan covered only 52 outpatient therapy sessions annually, so by August or September of each year, the Bryans were paying $60 out-of-pocket each time Kevin had an appointment, or roughly $3,000 a year. "I kept making the point to the insurer that it was cheaper to cover his visits than to have him wind up in the hospital," says Chris Bryan, but nothing changed.
Under the new parity provisions, and the annual cap on visits was lifted. Now, when Kevin visits his therapist, his parents are responsible only for a $15 co-payment. He is responding well to treatment and considering going to college next year.
Looking down the road, Chris Bryan says the family may also benefit from the provision in the health-care overhaul that allows adult children to stay on their parents' insurance plan until age 26. "We were starting to worry about how to get him coverage as an adult," she says.
Mental health advocates are particularly pleased that the health-care overhaul will also beef up coverage of preventive services, including screening for depression and alcohol misuse.
In September, the Department of Health and Human Services announced nearly $100 million in grants under the new Prevention and Public Health Fund. They include more than $20 million to help local behavioral health agencies integrate primary care into the mental health care they already provide, and another $5 million to establish a national resource center dedicated to the integration of physical and mental health care.
Integrated care is vital
Integrated care is critical, say experts. The life expectancy for someone with serious mental illness is 25 percent lower than that of the average person, according to Nordal, in part because of metabolic problems resulting from the long-term use of powerful psychotropic drugs. With ongoing integrated care, the severity of chronic mental illness can be reduced and lives saved, as doctors, therapists and other health care practitioners work together sharing information to make sure their patients' ongoing physical and mental health needs are addressed.
Of course, dealing with problems before they become chronic can be even more effective. According to the National Institute of Mental Health, half of the people with a mental illness have it by the time they're 14. But on average, people don't receive formal treatment for their illness until they're 24, says David Shern, president and CEO of Mental Health America, an advocacy group.
Early intervention — for example, teaching kids how to manage their emotions or educating grade school teachers about effective behavior management — can be effective strategies for keeping children from developing more severe, long-term emotional problems later on, say experts. "That's why routine screening and treatment is so important," says Shern.
© 2012 This information was reprinted with permission from KHN. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.