Insurers urged to provided equal coverage for mentally ill
Despite recently implemented mental health parity laws, sufferers of mental illness in New York State are rarely reimbursed for treatment, even if they have insurance coverage. A number of medical providers don't accept private insurance for treatment, due largely insurers' reluctance to pay out. In 2015, 29% of mental illness suffers said insurers rejected a claim they made following treatment, according to a survey conducted by the National Alliance on Mental Illness.

(UNTREATED: This is part of a series on the care of Staten Island's mentally ill. Click here for additional stories in the project.)

STATEN ISLAND, N.Y. -- Despite laws put in place to guarantee equal coverage for mental health treatment, insurance companies are denying mental health claims more often than physical health claims.

In 2015, 29 percent of survey respondents said that their mental health claim was rejected due to the private insurance company saying it was not medically necessary, more than twice the percentage reported for denied medical claims, according to a National Alliance on Mental Illness (NAMI) study.

Fourteen percent of medical claims were denied for the same reason, the study shows.

Affordable Care Act plans had lower total denial rates when compared to other private insurance but mental health claim denials were still almost twice as high as medical claim denials.

Claim denials, as well as low reimbursement rates for services and providers who don't accept insurance create financial burdens for many families, often forcing patients to choose between services they desperately need and services they can afford.

"Middle and working class people can't really afford the financial burden," Fran Zagor, president and CEO of the Staten Island Mental Health Society (SIMHS) told the Advance.

Leslie Moran, senior vice president of the New York Health Plan Association (NYPA), said it's not as simple as comparing mental health to physical health because the term "medically necessary" varies widely for both.

WHAT DOES MEDICALLY NECESSARY MEAN?

Moran said the NYPA has some "misgivings" about the NAMI statistic because physical claims are more defined than mental health in terms of medical necessity.

"Physical health claims -- i.e. a broken leg, doctor's visit for bronchitis, etc. -- are more defined, or more clear cut versus mental health claims where there might be a question about the appropriate number of visits within a time frame (does the patient need two visits per week?)," Moran stated.

The setting where mental health services are provided, such has inpatient versus outpatient treatment, comes in to play as well, she said.

Mental health providers say it is unfair for an insurance company to determine medically necessity for mental health treatment because treatment is more complex and insurance companies do not take into consideration the patient's medical history.

The NAMI report states that there has been little "clarity" about what criteria insurance companies use to determine what is or is not medically necessary.

"In the absence of uniform criteria, insurers have adopted their own standards and have often not been forthcoming about informing beneficiaries about these standards. This in turn has sparked concerns that insurance companies and managed care organizations deny claims for mental health care at far higher rates than other for medical care," NAMI said in the report.

When an insurance company denies a claim, they are required to provide a reason for the denial in writing and include information on how to appeal the process.

Additionally, the NAMI study does not acknowledge or include statistics regarding a person's ability to appeal the claim, Moran said.

"Both internal plan appeals and independent external appeals, and the percentage that are overturned on appeal, is not addressed in this data," she said, adding that it is not "really a fair comparison."

"In approximately 60 percent of disputes about medical necessity, the plan's decision is upheld by an independent external reviewer," she said.

PARITY LAWS IN PLACE



After decades of little to no fair coverage from insurance providers, Mental health parity laws were enacted to require insurance plans to have comparable coverage for mental health, addiction and other medical treatment.



The federal Mental Health Parity and Addiction Equity Act of 2008 prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable limitations on those benefits than on medical/surgical benefits, according to CMS.gov.

This federal law superseded New York state's "Timothy's Law," by replacing the required coverage minimum of 30 days of inpatient and 20 days of outpatient treatment with equal and consistent coverage for mental health treatment.

While parity laws have closed some gaps for mental health coverage, providers say that patient's needs are still not being met.

"The insurance companies say they meet the needs of their members but the reality is, it becomes clear when you're dealing with somebody who has a real issue and people on the insurance panel say 'We can't provide you with services,'" Zagor said.

Moran argued that Zagor's comment shows "provider's bias."

"It often comes down to a question of need versus want. In other words, providers want all the treatment for a patient that they can get the health plan to pay for, even when determination is made that the treatment isn't truly medically necessary," Moran said.

INSURANCE NOT ACCEPTED



While laws have been changed to make treatment more accessible, many treatment providers don't accept private insurance or Medicaid -- due in part to low reimbursement rates and new provider laws -- forcing those seeking treatment to pay out-of-pocket or forgo treatment altogether.

"Parents are calling us desperately looking for places to bring their children. Unfortunately, the rate of reimbursement is not high so we won't sign the contract with the insurance company because of it," Zagor explained. "Except there's nowhere else to refer them too."

She said the SIMHS will work with the families, allowing them to pay off the difference between what the insurance company pays and the cost of services.

Only 55 percent of psychiatrists accept insurance, compared to 88.7 percent of medical physicians in other specialties, a study published by JAMA Psychiatry shows.

Moran acknowledged that there are providers who do not accept insurance, but said it is each provider's decision and does not reflect the on private insurance companies.

The coverage parity law covers deductibles, co-pays, co-insurance, out-of-pocket expenses, annual and lifetime dollar limits, limits on frequency of treatment, number of visits, and other limits on the scope or duration of treatment.

"Health plans have an interest in making sure their members get the right are in the right setting at the right time, which applies to mental health services as well as physical health care. Plans work diligently to comply with the letter and spirit of mental health parity laws that ensure access to needed services," Moran said.

NAMI states that New York is "leading the nation" in terms of coverage parity and enforcement, however, obstacles still exist when trying to find and afford treatment.

"We have the expertise to deal with all of this. We provide a lot of training [for staff], we use evidence-based practices, there are psychiatrists available; in our setting, we have it all but it all goes back to having the right kind of reimbursement," Zagor said.