State budget cuts, insurance company rules block care for mentally ill

Daniel Workman

Mental health and substance abuse insurance coverage often lags behind medical and surgical treatment benefits. These deficiencies persist despite federal initiatives to bolster coverage.

In September 2010, the new federal Prevention and Public Health Fund granted:

  • $5 million to launch a national resource center integrating physical and mental health care.
  • $20 million to marry primary care with local mental health care.

Meanwhile, the Mental Health Parity and Addiction Equity Act (MHPAEA), which began being phased in July 1, 2010, seeks to bolster mental health coverage. The act prevents insurance companies from making their mental health coverage more restrictive than their coverage for medical treatments. For example, they can't charge higher co-payments and deductibles for mental health care or limit the number of mental health-related visits that are covered each year.

Mental health gaps

Still, despite these measures, gaps in coverage persist for treating addiction, depression and other mental illnesses, according to the U.S. Department of Labor.

Under MHPAEA, insurers can still:

  • Choose not to cover mental health benefits at all.
  • Exclude specific disorders.
  • Cover only mental health treatments that the insurer deems medically necessary.
  • Demand pre-treatment approval.

Moreover, MHPAEA does not apply to group health insurance plans with fewer than 50 employees.

Health care reform will establish state-based insurance exchanges that will be required to sell health plans with mandatory mental health and addiction benefits. Plans will be available to individuals and small groups, with coverage comparable to medical and surgical benefits, according to Kaiser Health News. But that provision of health care reform isn't scheduled to be carried out until 2014.

State budget cuts

In the meantime, state support for mental health services financed by a state's general funds as well as joint federal-state contributions to Medicaid. So, those without insurance or who are enrolled in Medicaid often find themselves at the mercy of their states' budgets -- and the economy -- when it comes to mental health care.

According to the National Alliance on Mental Illness (NAMI), state governments have cut $1.8 billion (8 percent) from overall mental health budgets from 2009 to 2011. Kentucky's 47.5 percent slash was the severest, followed by Alaska's 35 percent cut. Thirty other states plus the District of Columbia have pared their mental health budgets.

Data from the National Association of State Mental Health Program Directors (NASMHPD) reveal that states have cut (or have planned to cut) 3,930 psychiatric beds since 2010. That represents more than 8 percent of total bed capacity.

In March 2011, NASMHPD President Kevin Martone told Kaiser Health News said that because mental health service funds are dependent on states' general revenues, the economic downturn has been "more devastating on these services than to other safety net services for general health care." Also, mental health services received far less support from federal stimulus programs than what community health centers enjoyed.

There's more potentially grim news.

Federal stimulus package funding that have braced many state budgets expire June 30, 2011. Under federal Medicaid rules, many mental health services are optional benefits that can be cut.

Denied mental health claims

Because mental health benefits often occupy a gray area in the health insurance world, having insurance is no guarantee of coverage. To help ensure your claims are paid, Mental Health America (MHA) suggests the following:

  • Before starting treatment, verify coverage and required pre-approvals with your insurer.
  • Review your policy, and ask for help understanding contract information.
  • Learn your insurer's appeal processes, including maximum number of appeals, deadlines and required documentation.

Immediately appeal treatment-denied decisions by calling and writing your insurer. Copy an attorney on your correspondence. Also copy your state's insurance department, and ask whether your state supports claim reviews by external organizations.

Here are other important steps:

  • Document all communications, specifying dates, times and names of individuals you speak with.
  • Ask your insurer for the written definition of "medically necessary" that it uses for claim approval.
  • Ask your doctor to write a letter stating potential harm if treatment is denied.
  • Advise your insurer of your plans to contact your state insurance regulator for help.