[NYAPRS Enews] Parity for BH Coverage Delayed by Lack of Federal Rules: Stateline

[Harvey Rosenthal]

Parity for Behavioral Health Coverage Delayed by Lack of Federal Rules

By Michael Ollove
<http://www.pewstates.org/projects/stateline/about#michael-ollove>
Stateline November 30, 2012

 

Danielle Moles is anorexic, which in her case played out not only in a
near-starvation diet but also in obsessive running. She ran during
tornados. She ran in temperatures that fell to 20 degrees below zero and
froze her ponytail solid. She ran a marathon with a stress fracture in
her foot. She ran when she was supposed to be at birthday parties and
bridal showers and family vacations. She ran until she literally passed
out.

Even with all that exercise, Moles convinced herself it wasn't enough.
She denied herself liquids to punish herself. She purged. She abused
laxatives so frequently that she permanently damaged her digestive
system and wore the enamel off her teeth. Her body rebelled in other
ways as well: She stopped menstruating. She was persistently
light-headed and nauseated. She began having seizures. One particularly
awful night in 2008, she tried to end it all with a half-bottle of
Ativan.

There were more consequences to her destructive behavior. She
miscarried. Her marriage fell apart. Her career as a nurse foundered.

Doctors diagnosed Moles, now 32, with anorexia and depression, and
prescribed long-term care in a residential psychiatric facility. But
Moles' insurers said she wasn't covered for such care. About a year ago,
her insurer finally agreed to pay for three months in an Illinois
residential psychiatric facility. Those three months proved more
effective than anything she had tried previously.  Eight months after
Moles left the facility, her weight had stabilized at 120 pounds-only
five pounds less than her doctors recommend-and she hasn't run in a
year.

Moles doesn't understand why her insurance company resisted paying for
the residential care she needed, especially because it would have
covered lengthy in-patient care to recover from a stroke or heart
attack. "I don't understand why mental health isn't as recognized as
much as a physical condition," she says. "This is just as debilitating."

A Law but No Rules

Congress recognized that equivalence in 2008 when it passed the Mental
Health Parity and Addiction Act, which requires insurers to cover mental
illness and substance abuse treatment on an equal basis with physical
ailments. The law, which passed with substantial bipartisan support, was
supposed to eliminate two-tiered systems for co-pays, deductibles or
treatment limitations.

The Obama administration's Affordable Care Act will vastly extend the
reach of the 2008 law. The older law does not require health insurance
plans to offer behavioral health coverage, although if they do it must
be on par with benefits provided for medical and surgical care. But the
ACA does require that all health plans sold on the soon-to-be-created
state health insurance exchanges eventually offer mental health
coverage. Those plans, then, will all be required to observe the federal
parity act.

The problem, behavioral health advocates say, is that more than four
years after President George W. Bush signed the parity bill into law,
the Obama administration has yet to complete the federal rules that
would enable states to enforce it.

As a result, behavioral health may actually have fallen further behind
since passage of the law. In May, the U.S. Government Accountability
Office released a report showing that health insurance plans have
actually increased the number of exclusions for mental health and
addiction treatments since the law was enacted. In 2010 and 2011, for
example, 15 percent of the plans surveyed by the GAO were excluding
residential mental health, a significant increase from 2008.

"Hundreds of thousands of Americans are being denied their rights under
the federal parity law," says James Ramstad, a former Republican
congressman who originally introduced the House version of the bill in
1996 at the request of his friend and fellow Minnesotan, the late
Democratic Senator Paul Wellstone, whose name is memorialized on the
law. Wellstone was killed in a plane crash in 2002. "It took 12 years to
pass that parity act and four years later, we still have no rules and
therefore no enforcement," says Ramstad. "It's unconscionable."

Ramstad and another former congressman, Patrick Kennedy, whose father,
Sen. Edward Kennedy, also championed the law after Wellstone's death,
have been convening meetings across the country in which experts and
patients - some of them of them soldiers returning from war in Iraq or
Afghanistan - testify in support of the law. The motive of the meetings,
Kennedy says, is to publicize the parity law and prod the Obama
Administration to act.

"Right now, there are no regulations telling the insurance companies how
to comply," says Kennedy. "A law without rules isn't worth the paper
it's written on, and what that means is that insurance companies can
continue to do business as usual."

Victoria Ventril, Connecticut's Health Advocate, agrees. She says
pushing insurers to observe parity is difficult without the specific
requirements federal rules would spell out. "It makes it very difficult
to make arguments about whether the criteria the insurers are using pass
muster or not."

The U.S. Department of Health and Human Services had not responded to
multiple requests for comment at the time this article was published.

Some Progress

Some states, including Connecticut, Maryland, Maine, Oregon, and
Vermont, have enacted strong laws to beef up coverage of behavioral
health, but those statutes do not cover all health insurance plans,
including those issued by the many large employers which insure their
own workers.

States that refuse to enforce the parity act after HHS releases the
rules likely will face lawsuits from patients, as well as pressure from
the Obama administration, which has the authority to enforce the law if
the states do not.

Even without the final rules, the broad outlines of what parity will
look like are relatively clear: Insurance companies will not be
permitted to impose more restrictive spending limits on mental health or
addiction benefits than they impose on medical and surgical benefits.
They will not be able to limit the frequency or duration of mental
health treatment more severely than they do for other forms of care, nor
will they be allowed separate deductibles or more restrictive
authorization rules.

Andrew Sperling of the National Alliance on Mental Illness says that
even without final federal rules, insurance companies generally have
eliminated separate deductibles and scrapped unequal spending limits.
But Sperling and other advocates say insurers continue to disallow
mental health and addiction treatments in non-hospital based facilities,
and also to exclude types and levels of treatment for behavioral
patients, while covering a full range of treatments for medical
patients. They also say that behavioral health patients are often
subject to reviews and criteria that are not required of patients on the
medical and surgical side.

Fail First

Substance abuse treatment advocates are particularly troubled by the
requirement that people with addictions fail at lower levels of care
before they are approved for more intensive treatments. They say the
"fail first" requirement would never be tolerated for medical and
surgical patients.

"It's a classic example of discrimination and a moral overtone that is a
remnant of the past that still lingers," says Beth Middlebrook, legal
coordinator of Watershed Addiction Treatment Programs. "It comes from
the belief that the alcoholic is a bad person as opposed to a person
with a bad disease."

Susan McClanahan, Danielle Moles' psychologist, is convinced that
Danielle has paid a heavy price because of the unequal treatment
accorded behavioral health patients.

"If she had been able to have a residential stay earlier," says
McClanahan, "the course of her illness would not have been so long."

There might have been other benefits as well. Had Moles gotten the help
she needed at the beginning, her treatment might have cost her insurers
roughly $80,000 instead of the $500,000 to $750,000 she estimates they
eventually shelled out. (Moles estimates she has paid $150,000 out of
her own pocket.) She also might have avoided the physical ailments she
has today that resulted from her mental illness, including seizures and
chronic pain in her back and knees.

"I'm terrified that I won't have the life of normalcy I long for," she
says. "I want to have a relationship again. I want to have children. I
want a profession and career that I love."

She can't help wondering whether she'd already be living that life it if
she had gotten the help she needed when she needed it.

 

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ral-health-coverage-delayed-by-lack-of-federal-rules-85899433333 

 

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