Mental Health Bill Passed out of HELP Committee

Yesterday, the Senate Health, Education, Labor and Pensions Committee marked up a major mental health bill, S. 689. The bill is an excellent step forward for mental health issues. We are glad to see this reported out of Committee and hope Congress passes it soon. The bill does a number of things including:

• Expands the use of positive behavioral interventions and early intervening services in schools to reduce over-identification of individuals with disabilities and reduce disciplinary problems in schools.
• Allows funds from the Elementary and Secondary Education Act of 1965 to be used for school-wide intervention services and to create or update school emergency management plans.
•  Reauthorizes the Youth Suicide Early Intervention and Prevention Strategies grants to states and tribes (about $30 million to be appropriated for each fiscal year from 2014 to 2018).
• Reauthorizes the Mental Health and Substance Use Disorder Services on Campuses grant programs;  and allow for the education of students, families, faculty and staff to increase awareness and training to respond to students with mental health and substance use disorders (about $5 million to be appropriated for each fiscal year from 2014 to 2018).
• Reauthorizes grants to states, political subdivisions of states, American Indian tribes, tribal organizations and nonprofit private entities to train teachers, school personnel and emergency services personnel to recognize the signs and symptoms of mental illness (about $20 million to be appropriated for each fiscal year from 2014 to 2018).
•   Reauthorizes the National Child Traumatic Stress Initiative, which supports a national network of child trauma centers (about $46 million to be appropriated for each fiscal year from 2014 to 2018).
•  Requires a Government Accountability Office (GAO) report on the federal requirements impacting access to mental health and substance use disorder treatment related to integration with primary care, administrative and regulatory issues, quality measurement and accountability and data sharing.
•  Directs the Substance Abuse and Mental Health Services Administration to advance the education and awareness of providers, patients and other stakeholders regarding FDA-approved products to treat opioid use disorders.
• Requires a GAO report on the utilization of mental health services for children.
• Requires a GAO study on the status of the implementation of the recommendations outlined in a report to President George W. Bush in 2007 by the secretaries of Health and Human Services and Education and the attorney general regarding the Virginia Tech shootings.

While this bill does not address eating disorders specifically (or any other specific illness or disease) it is a very important piece of legislation. It addresses many critical areas of mental health care and we applaud the HELP Committee for passing it and urge the Senate to take it up quickly and pass it. The EDC is closely monitoring and actively working to make sure this bill passes.

*Summary from Congressional Quarterly

Is Parity Failing You?

Have you been denied coverage for your eating disorders treatment in the last five years that may be a violation of the parity law?  If so, then we need to hear from you.  The Mental Health Parity and Addiction Equity Act of 2008 requires insurance companies to ensure that co-pays, deductibles and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the requirements or limitations applied to medical/surgical benefits. Yet we often hear from people that were denied equal coverage by their insurance companies. Now we need to hear from you.

Have you experienced any of these common problems?

1.  Insurance companies deny treatment as they do not consider the care as "medically necessary".  They use their own definition of medical necessity, versus the standard of care and best practices in the treating community.

2. Provider reimbursement rates are too low, so the provider has to offer services out-of-network and the patient has to pay a higher out of pocket for their treatment.

3. The insurance company has labeled my treatments as “experimental” or "experiential" and therefore are refusing to pay for those treatments, leaving the patient to pay 100% out of pocket, or go without.

4. The insurance company says that my plan does not cover residential treatment or intensive outpatient care.

5. The insurance company says that my plan does not cover inpatient or residential treatment unless it is provided in an acute care hospital, but most of the treatment providers are non-hospital based facilities (e.g. a residential care facility specific for eating disorders treatment).

6. The insurance company says that they do not authorize any inpatient treatment at all for my anorexia, bulimia or other eating disorder, and that I must be treated only on an outpatient basis.  

7. I have requested from my insurance company the reason why they have denied my care and they will either not respond to my requests for further information, or they refuse to tell me what they do for medical and surgical care, or they refer me to a website that I cannot discern any information from.

8. Outpatient sessions are being limited by utilization review (also known as medical necessity review) and this is not being done for medical and surgical conditions.

9.  Insurance companies deny patients treatment (or tell them up front that their treatment isn't a covered benefit) because eating disorders are not a biologically based or serious mental illness (BBMI and SMI).

10.  Insurance companies deny people treatment because it is considered "educational services".

11. Any other reason you were denied treatment for your eating disorder in a way that is more restrictive than medical/surgical coverage (e.g. visit limits).

What You Can Do?

If you were denied coverage for any of the 11 reasons listed above. Please let us know right away by emailing Melanie Morris at mmorris@eatingdisorderscoalition.org. If you have your denial letter please attach it. We’ll help you use it to let Congress and the Administration know that Parity for eating disorders coverage must be enforced and that any regulations should explicitly state this.

What is Next?

After a law passes, the Administration promulgates regulations (just a fancy way of saying interprets the law and gives some guidance on how it should be interpreted by the insurance companies). However the Administration has yet to put out the final regulations on Parity—it has been four years!!! We need to ensure that when these regulations come out they give strong guidance to the insurance companies on how eating disorders should be covered at parity.

Final Rule for the Exchanges Issued

The EDC continues to both monitor and influence the implementation of the Affordable Care Act.  On February 20, 2013, the Administration offered the Final Rule for the Exchanges.  Here is our summary of this rule.

The Affordable Care Act (ACA) requires that all of plans offer a core of benefits, known as the EHB. HHS has issued a final rule on the Essential Health Benefits (EHB’s)--see the full regulation here.  The EHB’s must include services in:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Benchmark Plans

Because of the provision in the ACA that requires the EHBs to be equal in scope to benefits offered by a typical employer plan, the final rule states that all plans offer benefits equal to the benefits offered by the benchmark plan. They must cover mental health services at parity. However, the plans can substitute benefits within a category (excluding prescription drug benefits) as long as the substitution is actuarially equivalent. The final rule defines EHB based on a state-specific benchmark plan. States can select a benchmark plan from among several options, including the largest small group private health insurance plan by enrollment in the state.

The benchmark plan options include: (1) the largest plan by enrollment in any of the three largest products by enrollment in the state’s small group market; (2) any of the largest three state employee health benefit plans options by enrollment; (3) any of the largest three national Federal Employees Health Benefits Program (FEHBP) plan options by enrollment; or (4) the HMO plan with the largest insured commercial non-Medicaid enrollment in the state.

Twenty-six states selected their own benchmark and the final rule states that if the remaining states that do not make a selection, HHS will select the largest plan by enrollment in the largest product by enrollment in the state’s small group market as the default base-benchmark plan. The selected benchmark plans are already finalized for benefit year 2014.

The final rule provides guidance on how the state will supplement the benchmark if the plan is missing any of the ten categories of benefits. The provisions for supplementing are the base-benchmark plan where it does not adequately cover any of the ten categories of EHB.  Plans can not include discriminatory benefit designs and must ensure a balance among EHB categories

Parity:

The statute requires that all plans covering EHB offer mental health and substance abuse

service benefits, including behavioral health treatment and services.  Coverage of EHB must provide parity in treatment limitations between medical and surgical benefits and the mental health and substance abuse benefits required to be covered as EHB in both the individual and small group markets. 

Approximately ninety-five percent of those with coverage through the three largest small group products in each state had mental health and substance abuse benefits. According to the final rule, “a study of implementation of parity in the FEHBP plans as well as research into state-passed mental health parity laws have shown little or no increase in utilization of mental health services, but found that parity reduced out-of-pocket spending among those who used mental health and substance abuse services.”   

Next Steps:

As the ACA is implemented and as the Exchanges go live in 2014, it is essential that we ensure that all mental health services are covered at parity in each of the states and that all levels of care are covered. We need to continue to advocate at both a state and federal level to ensure people with eating disorders are able to receive the treatment and care that they both need and deserve.

Please see our benchmark survey to better understand the coverage of eating disorders in the benchmark plans. To understand how the Exchanges are being implemented in your state, see this interactive map from the Kaiser Family Foundation.

EDC Survey of Benchmark Plans

See the full document here.

Beginning on January 1 2014, the Affordable Care Act (ACA) requires that all (non-grandfathered) individual and small group health insurance plans sold in a state cover certain essential health benefits (EHB’s). In January 2013, the Eating Disorders Coalition (EDC) surveyed all of fifty states and the District of Columbia’s proposed benchmark plans and discovered a wide disparity in the anticipated mental health service coverage between states. 

Executive Summary

There exists a wide disparity in anticipated mental health and substance abuse service coverage between states, particularly as it relates to residential care and eating disorder care.  This troubling disparity is of great concern for people struggling with eating disorders and other mental health and substance abuse issues across the country.

According to our survey, twenty-seven of the benchmark plans severely limit mental health services. Seventeen of these plans have day limits on mental health services and nine states have exclusions for residential services. In some cases, the states with limits on mental health do not have the same limits on substance abuse services; in other cases limits are extreme for both mental health and substance abuse. Given that similar limits are not seen in medical services, the disparity on quantitative day limits and unequal exclusionary status should not be allowed under Mental Health Parity.

In contrast, our review indicates that twenty-four states have strong mental health coverage, without non-equitable service limits. Vermont has the strongest coverage for eating disorders and Connecticut, Idaho, and Maine also having very strong plans.  

With half of the states including equitable coverage for mental health and substance abuse services, there is strong evidence that plans can and do include equitable and inclusive treatment for mental health and substance abuse. There is a pressing need for the other half of the nation to provide for inclusive coverage of these illnesses. As the benchmark plans are implemented, it is imperative that states offer equitable and adequate access to care for people suffering with mental health conditions, including eating disorders. It is also imperative that all Benchmark plans follow Mental Health Parity.  We urge advocates to monitor and influence the implementation in their states, specifics for each state can be found at http://healthreform.kff.org/state-exchange-profiles-page.aspx.

Download the entire document here.