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4 ways a mental health denial fight could affect brokers

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Some states have been trying for years to get health insurers to cover mental health services in a way above and beyond what federal law requires.

Washington state regulators are about to take the fight over mental health services parity to the mail.

Mike Kreidler, the state’s insurance commissioner, has told insurers in his state to identify any policyholders who have mental health claims denied because of blanket or categorical coverage exclusions since Jan. 1, 2006, for large-group plan enrollees, and since Jan. 1, 2008, for other enrollees, and tell those consumers that they have a right to have their claims re-evaluated.

“The Office of Insurance Commissioner will independently inform consumers that each carrier must implement a process for allowing improperly denied claims to be reevaluated, and will encourage consumers to contract our insurance consumer hotline should they have complaints, questions or concerns,” Kreidler says in the letter.

Kreidler is acting in response to a Washington State Supreme Court ruling on the state’s own mental health parity law. The 2006 law bans coverage exclusions for medically necessary mental health services.

The U.S. Department of Health and Human Services (HHS) has now included access to mental health services in what it defines as the basic package of essential health benefits (EHB) that a major medical plan that complies with the Patient Protection and Affordable Care Act (PPACA) ought to cover. 

Determining just what the HHS rules really mean and how they will really work may take years.

The two major federal mental health parity laws — the Mental Health Parity Act of 1996 and its successor, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), have required large-group policies that offer behavioral health benefits to make the benefits comparable to the other benefits. Neither law requires a plan to offer behavioral health benefits.

Washington state’s top court ruled that insurance regulators can apply the stricter state parity law to individual and small-group coverage going back to Jan. 1, 2008, and to Jan. 1, 2006, for consumers who were enrolled in large-group plans.

What could Kreidler’s move mean for agents and brokers? Here are four possibilities.


1. This may be one of those increasing common opportunities for the solution creators in the health insurance and benefits business to stand out from the order takers.

The insurers in Washington state are going to be telling consumers to communicate with them.

The insurance commissioner is going to be telling consumers to communicate.

If you’re in that state — or in another state with a similar situation — maybe it would be useful to the consumers, and to you, if you encourage the consumers to call you first.

2. The insurers may come to value any agents, brokers or other benefits professionals who can help them deal with this situation.

Health insurers may find that they rely more on producers to find the affected consumers, reach them, and manage communications with them in an efficient and mutually satisfactory fashion.

3. Health agents and brokers can use a situation like this to explain how they earn their commissions.

Eventually, exchange Web sites are supposed to give consumers some clue as to how carriers actually pay claims. Experienced agents and brokers can use their experience and information sources to give customers an idea of how coverage might actually work in the real world where they really live.

4. Eventually, prices might rise or market competition might decrease.

Regulators like to get consumers important protections and benefits “for free” by creating laws and regulations requiring those protections and benefits be provided, through the magic of the government telling the insurers to do that.

In some cases, insurers may find that meeting a requirement like mental health parity benefits may cost them little, or even save them money. Some have suggested that adding solid mental health benefits to a benefits package might ultimately save money, by reducing overall claims.

But, if that prediction proves to be optimistic, and parity is more expensive than advocates think, insurers might increase the cost of the coverage to pay for the benefits, cut the benefits they offer, or leave the market.

See also:

5 ways to ease benefits buyers’ PPACA daze

Economist: Bad PPACA exchanges cost users dearly


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