The world of health insurance and managed care is confusing, especially when it comes to mental or behavioral health coverage (interchangeable terms), even for the lawyers who compose our clientele at LCL. In fact, assistance in searching for adequate and covered treatment is one of the key reasons that lawyers come to LCL rather than seek help on their own. Right now, things are changing in mental health insurance coverage (largely for the better), though few consumers are up to date on these changes (which some insurers have not seemed eager to mention, e.g., in their on-line benefits information).
Mental health coverage has long been the “stepchild” of health insurance, partly because it is more difficult to evaluate or define these conditions with precision, or to determine a specific optimal treatment plan. That very vagueness has served as an excuse for inadequate coverage. When I was first licensed as a psychologist in 1981, before managed care, most people in Massachusetts had an old-fashioned Blue Cross Blue Shield policy. By law, those policies covered up to $500 a year in mental health coverage. Believe it or not (partly because, even then, the insurer gave itself a discount), that was enough for at least 10 sessions. Nowadays, coverage is generally defined by number of services (which helps accommodate inflation), and most people have HMOs, which require “pre-authorization” before subscribers can actually utilize these benefits.
In one form or another, insurers have set fairly arbitrary maximums in mental health coverage, even while there were no such maximums for coverage of most physical health conditions. Sick as you might be, even with severe mental illness, once you had used up your maximum for the year (or, occasionally, your lifetime), you were on your own. In 2000, more or less concurrently with a number of other states, Massachusetts passed its first Mental Health Parity law, which removed predetermined maximums from coverage for psychiatric conditions seen as largely biological in nature. These were:
♦ Schizophrenia
♦ Schizoaffective Disorder
♦ Major Depression
♦ Bipolar Disorder
♦ Psychotic Disorders
♦ Delirium and Dementia
♦ Obsessive-Compulsive Disorder
♦ Panic Disorder
♦ “Affective Disorders” (defined slightly differently by different insurers)
In addition, the 2000 law stipulated that, for most other conditions, the maximum number of outpatient visits per year could not be fewer than 24 for adults (thus every Massachusetts-based insurer began covering 24 visits), with no limits for children. Excluded from the law entirely were alcohol and drug dependence, which are often covered up to just 8 sessions per year. (I am not focusing, here, on the maximums for inpatient hospital stays, since those are virtually always kept extremely brief regardless of stated maximums.) It always seemed very curious to me that alcohol and substance dependence were handled this way, since the biological aspects of those behavioral disorders are so central.
What’s new is that, as of this past July 1, Mass. state law has added four more diagnoses (including chemical addictions) to the list of those covered without a hard-and-fast maximum:
♦ Alcohol/Drug Abuse and Dependence
♦ Eating Disorders
♦ Post-Traumatic Stress Disorder
♦ Autism.
This state law does not apply to (a) self-insured plans [where the money that pays the claims comes directly from the employer], (b) MassHealth, or (c) Medicare.
There is also a new federal parity law coming down the pike. It was actually bundled with the measure congress passed late in the Bush term to permit the massive bailout of financial institutions (in this case the “pork” going toward what I regard as a good cause). As of January 2010,
♦ No plan is required to offer mental health coverage, but if it does (which is mandatory in Massachusetts), the coverage for all legitimate mental health diagnoses must be equivalent to coverage for medical/surgical procedures.
♦ It applies even to self-insured plans, but excludes employers with no more than 50 employees.
When the state and federal laws are in conflict, the more consumer-friendly one generally applies.
Two caveats:
(1) Who can say how Health Care Reform (which I support in principle) may ultimately be worded, and whether, as some kind of trade-off, it will override these legislative measures. In any case, I assume it will not take effect before 2011.
(2) Despite the removal of automatic maximums, the insurers will continue to require pre-authorization—that is, HMOs will cover only those services that they have determined are “medically necessary” for an individual. That is a very slippery concept when it comes to mood and behavior problems. In truth, even with reform or with a “public option,” some kind of mechanism is needed to prevent wasteful spending on unnecessary health care. I do wish, however, that someone would come up with a better means of accomplishing that purpose than the cumbersome,(unpaid) time-consuming, and privacy-reducing forms that providers and their patients/clients often face.
In any case, if you are in need of assistance, now is a good time to look for the right therapist. LCL can help with that process if you are a Massachusetts lawyer, law student, or judge, or a family member of people in those categories. Understand that LCL itself does not use your health insurance – our primary service is to evaluate and refer (not to provide ongoing therapy), and is funded through lawyers’ annual licensing fees. We do, and must, take your health insurance into account in the process of our efforts to refer you for further services.
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Update Feb 2010: You may have noticed that we are not hearing anything about the federal parity law from our insurance providers. As a provider, I can tell you that when I look up new patients' eligibility on-line, there are still references to the 24-session/year maximum for diagnoses not on the Massachusetts list of parity diagnoses.
Based on some web searching, it seems that, although in one sense the federal parity law is already in effect, in another sense it is still in a non-final, feedback-gathering phase until July 1 -- so that may be the point at which it will really kick in.
In addition, while most interpreters of the law see it as applying to all mental health diagnoses (thus not just the ones that Massachusetts has deemed parity-worthy), some commentaries note that this only applies to coverage of conditions included in the plan. Although I have seen no evidence of this as yet, it seems possible that an insurance company could decide, for example, that they do not cover substance absue at all, or that they do not cover adjustment disorders at all. My impression is that they could get away with that gambit, because the law only states that whatever is covered must be covered equivalently to medical/surgical conditions, and that providing no coverage whatsoever, for a given condition, gets around that requirement. We'll see. In either case, we should be beyond the 24-session limit that is probably still being shown in your insurance provider's information packet. Caveat: I am a psychologist and not a lawyer or policy expert. My only expertise is that I've been dealing with health insurance claims, authorizations, and limitations (though a series of changes) since 1981 as a working clinician, and that I've taken the time to look up this information extensively on line.
