Dr . Robert Feder says he spends about a quarter of his time on the phone with insurance companies trying to get care approved for his patients.
These requests are often denied, he says, and criteria for "medically necessary" care are often overly restrictive or not transparent.
And the Manchester psychiatrist says he also argues frequently for approval of inpatient care. These are just a few examples, Feder says, of why the promise of parity – treatment for mental health that's on par with physical issues – remains unfulfilled, despite new laws, new rules, and lawsuits that have sought to ensure parity.
Feder, who is a member of the Council on Addictions for the American Psychiatric Association, joined The Exchange to discuss the status of mental health parity in New Hampshire. (You can hear the full conversation here.)
Mental Health Parity Under Insurance Law
A state Senate bill to be considered in the House on Wednesday, April 24, addresses mental health parity, authorizing the health insurance commissioner to enforce the parity law of 2008 and assess insurers on issues of parity.
The Mental Health Parity and Addiction Equity Act of 2008 required insurers that cover mental health and substance abuse benefits to cover them to the same extent that they cover medical/surgical benefits.
The Affordable Care Act, along with subsequent rules and laws, strengthened mental health parity, and states can also issue their own requirements.
But according to a 2017 natioanl survey by the National Alliance on Mental Illness, significant barriers remain for patients seeking mental health treatment and support – including high rates of denials of care by insurers, high out-of-pocket costs, difficulties accessing psychiatric medications, and problems finding psychiatrists and other mental health providers in health insurance networks.
Feder says his patients face similar challenges regularly.
“At least half the prescriptions I write have to be approved by the insurance company before they'll pay for them,” he said. The wait can be one to three days. “These are prescriptions that people need immediately or they're going to become psychotic or they're going to go out and use heroin or fentanyl on the street again," he said.
Andrea Rancatore, director of substance-use-disorder programming for N.H. Healthy Families and Ambetter for N.H (together, they provide insurance for about 100,000 Granite Staters), says the insurers she represents have been working to ease these situations.
“Parity is vastly important, and we've worked very hard to show that in terms of really helping our members to access care,” she said.
“We listened to concerns around prior authorization and removed the barrier for Medication Assisted Treatment (MAT) service – for opioid use disorder treatments,” she said. “We hear things like this and we want to make changes that support our members, that decrease any burden that the provider has regarding prior authorizations.”
Jennifer Patterson, Life and Health Director at the N.H. Insurance Department, says mental-health parity has been a priority for her department. (At a hearing regarding SB 272, Patterson said the bill would enhance her department's authority to assess parity though the department did not take a position in favor or against.)
"We've really focused a lot on consumers. And we're really eager to hear from consumers – both because we can help them navigate that system often times, and also the information we get from calls to our consumers' unit is important information for us as we're regulating the insurers conduct."
But Feder says his patients already have so many challenges, including facing stigma, that simply picking up the phone to report denial of treatment or some other barrier can be overwhelming.
All it takes is one barrier, one co-pay too high, one deductible too high, one pre-authorization too many -- and you don't have access to the care. -- Lucy Hodder, of UNH School of Law’s Institute for Health Policy and Practice.
That's where new guides and other materials designed for this population can be especially helpful, says Lucy Hodder, professor of Law and Director of Health Law and Policy at the UNH Institute for Health Policy and Practice. (See links to these guides, here.) Anyone in need of help is also encouraged to call 211.
“We've really tried to get out quick guides and information,” she said. “You can appeal denials, advocate by calling the insurance department. We all need to be working together to make sure people in this population... know what to do, especially for people in a crisis – to activate both the treatment provider community and also to activate their insurance coverage because they should be treated similarly.”
In addition, the state's new Doorwaysystem, designed to connect people with addiction treatment, will help, Hodder said. “They're building up the access points so people can be assessed and transferred to the right provider at the right time. That's not going to change the situation over night, but it will help. Also we training providers around Medication Assisted Treatment (MAT), so we're trying to make sure every primary care office in the state has someone able to provide and support MAT."
As Hodder sees it, despite much room for improvement when it comes to parity – there has been an unmistakably positive shift. "We are much more often realizing our mental health is absolutely synonymous with our physical health. Now that we have so much more access to claims data, I think there's universal acceptance that all of us at some point in our lives will have a mental health issue. And mental health is oftentimes the driver of our physical health issues."
"We are much more often realizing our mental health is absolutely synonymous with our physical health."
Hodder says the Affordable Care Act made mental health parity much more enforceable."A lot more people are trying to access mental health coverage, and insurance companies are really following suit. They're making sure you can access mental health treatment as well as physical health treatment,” she said.
Attempts to dismantle the ACA have raised concerns that mental health and substance use disorder treatment benefits may no longer be considered essential health benefits, she said. Meanwhile, although Medicaid has benefited from parity laws, Medicare remains excluded, leaving the elderly vulnerable to inadequate mental health care.
Patterson says her department has been working to enforce mental health parity, reviewing all insurance plans before they are sold in the state. And recent changes have helped enhance parity, she said.
“In 2014, mental health coverage became required as essential for individual and small-group market plans. In 2016, when the Medicaid expansion population acquired insurance through private market plans, there was a huge expansion of coverage”
The department is in the midst of a broad look at parity compliance issues – with a report due out this summer.
Meanwhile, there are stubborn problems that also affect parity: longstanding workforce shortages in the field of mental health and substance use disorder treatment. Low Medicaid reimbursement rates make it especially hard to attract and retain these workers, according to mental health advocates. It's an issue lawmakers have been attempting to address during the budget process.
