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Mental health: Will it fall between the insurance cracks?

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Regulators have to do more to make sure that two major federal laws already on the books really improve access to mental health care insurance benefits.

Witnesses delivered that message today in Washington at a hearing on the state of the U.S. mental health care system that was organized by the Senate Health, Education, Labor and Pensions Committee

The committee organized the hearing in response to the mass shooting in Newtown, Conn., to look at how the United States might be able to improve the way it manages psychological problems that lead to violence.

Pamela Hyde, the administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), noted at the hearing that “most people who are violent do not have a mental disorder, and most people with a mental disorder are not violent.”

“Demographic variables such as age, gender and socioeconomic status are more reliable predictors of violence than mental illness,” Hyde testified, according to a written version of her remarks posted on the committee website. ” These facts are important, because misconceptions about mental illness can cause discrimination.”

Patients and their families now get 69 percent of the cash used to pay for mental health care from state and federal government programs, 12 percent from their own personal resources, and 27 percent from private insurance plans, Hyde said.

One of the major laws governing private health insurance benefits for mental health care, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), affects insured and self-insured group health benefits.

The MHPAEA does not require an employer to offer coverage for mental health or substance use disorders.

If an employer with 50 or more employees does offer mental health or substance abuse benefits, then the financial requirements and treatment limits for the behavioral health benefits can be no more restrictive than the typical requirements for benefits for other types of disorders.

The federal departments in charge of implementing the MHPAEA — the U.S. Department of Health and Human Services, the U.S. Labor Department and the U.S. Treasury Department — put the law into effect with temporary regulations in July 2010. A lack of final regulations interferes with efforts to enforce the law, critics say.

Another law, the Patient Protection and Affordable Care Act of 2010 (PPACA), is set to require all non-grandfathered individual and small group plans to offer an “essential health benefits” (EHB) package that includes coverage for mental health and substance use disorder services starting Oct. 1.

The Obama administration intends to move forward by issuing a final rule on the EHB package and PPACA mental health benefits parity requirements in February, Hyde said.

The administration also intends to put out an MHPAEA final rule, Hyde said.

Michael Hogan, a former New York state mental health office commissioner and the chairman of the President’s New Freedom Commission on Mental Health, said improving the mental health system “must begin with a realization that we have begun to take big steps away from an approach that was both separate an unequal.”

Going forward, to get the most out of the new, expanded access to mental health care benefits, mental health care providers should be providing “collaborative care” in primary care office settings, Hogan said.

“Station a mental health practitioner in the practice,” Hogan said. “Screen for mental health problems, measure progress, allow billing for basic mental health services like educating patients about managing their depression, and ensure that a psychiatrist or other specialist is available for consultation.”

The country also needs better programs to help people who are showing signs of having psychotic disorders find and stay on effective medications, and get and keep jobs, Hogan said. 

Dr. Bob Vero, chief executive officer of Centerstone, a community mental health center in Tennessee, testified that the Obama administration needs to ensure that “behavioral health has a seat at the table” in new, PPACA-driven efforts, such as the Medicare “accountable care organization” (ACO) pilot program, to improve coordination of care. 

Hogan said he has concerns about having the people who manage general health care take over managing care for people who are dealing with serious mental illness.

Although the idea of integrating behavioral care with general primary health care is a good one, “we do not yet have national standards for the quality of care for people with serious mental illness, so the transition away from expert leadership is risky,” Hogan said. “We failed to maintain focus during an earlier era of deinstitutionalization; we must not make this mistake again.”

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