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Mental Health

as an essential benefit under Health Care Reform

Every qualified health plan (ObamaCare compliant-meeting the 10 essential benefits) must provide parity coverage for mental health and substance use services resulting in no added treatment limits and no extra costs.

Learn More ⇒

NAMI (National Assoc of Mental Illness) Website, Insurance & Health Care Reform Section

More than 43 million Americans suffer from depression, anxiety, and other mental health conditions, according to the most recent federal data. But more than half the people who felt like they needed help last year, never got it. Even people who had insurance complained of barriers to care.  Narrow Provider Lists?  Some said they still couldn’t afford it; some were embarrassed to ask for help. Others just couldn’t get through the red tape.

Learn More ==>

Dealing with social & mental problems can cut health care costs CA Health Line 1.23.2017

Information, links and resources

May is Mental Health Awareness Month

Mental Health Parity Act 1996 Wikipedia

Parity – Using Employer Sponsored Plan SAMHSA 8 page pdf

I’m not sick & don’t need help – Book

 

#California Mental Health Insurance Parity
AB 88 
  was passed in 1999.  CA Insurance Code §§10144.5.  Health and Safety Code§1374.72 

AB 88 Summary:

AB 88 prohibits health plans from basing medical necessity denials on whether the admission for mental health services was voluntary or involuntary, WIC 5150 hold  CA Legislator * or on the method of transportation of the patient to the health facility.

See below about mandate to cover Severe Mental Illness!

This bill also requires plans that offer mental health services (Individual & Families * Medi-Cal * Employer Groups)  to have information on their website that will assist enrollees in accessing mental health services.  SB 1553  §1368.015, §1367.015Health & Safety Code Blue Cross / Anthem Mental Health Procedures

Insurance Code §10144.5

(a) Every policy of disability (health) insurance that covers hospital, medical, or surgical expenses in this state* … shall provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child, … under the same terms and conditions applied to other medical conditions,

(b) These benefits shall include the following:

(1) Outpatient services.

(2) Inpatient hospital services.

(3) Partial hospital services.

(4) Prescription drugs, if the policy or contract includes     coverage for prescription drugs.

How to obtain, get or find these benefits?

(c) The terms and conditions applied to the benefits required by this section that shall be applied equally to all benefits under the disability (Health, Medical)  insurance policy shall include, but not be limited to, the following:

(1) Maximum lifetime benefits.

(2) Co-payments and coinsurance.

(3) Individual and family deductibles.

   (d) For the purposes of this section,
severe mental illnesses”
shall include:

(1) Schizophrenia  schizophrenia.com/ *** WebMD

(2) Schizoaffective disorder. ***  WedMD

(3) Bipolar disorder (manic-depressive illness). bipolar.com/***  WebMD

(4) Major depressive disorders. ***  WebMD

(5) Panic disorder. ***  WebMD

(6) Obsessive-compulsive disorder.***  WebMD

(7) Pervasive developmental disorder WebMD  or autism. *** Web MD

(8) Anorexia nervosa. *** WebMD

(9) Bulimia nervosa.  ***   WebMD

(e) For the purposes of this section, a child suffering from, “serious emotional disturbances of a child” shall be defined as a child who

(1) has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders,  other than a primary substance use disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected developmental norms, and …

CA Insurance Commissioner letter to All Health Insurance Companies to comply with SB 855 to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.  Blue Shield Summary & FAQ’s *

1374.72.   (a)

(2) “mental health and substance use disorders” means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders.  

(g) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplementdental-only, or vision-only insurance policies.  Autism 7.1.2012 SB 946  §10144.5.

So, one must compare AB 88, with the

EOC Evidence of Coverage, which you have a right to receive prior to purchasing coverage and the

Essential Benefits under Health Care Reform, namely Mental Health.

The Mental Health Parity Act of 1996 (MHPA)

 

MHPA is a federal law that may prevent your group health plan from placing annual or lifetime dollar limits on mental health benefits that are lower – less favorable – than annual or lifetime dollar limits for medical and surgical benefits offered under the plan.  Learn more on Wikipedia Mental Health Parity Act 1996   

The act removes separate treatment limitations for mental health and chemical dependency benefits (including number of visits, days of coverage, and annual dollar limits) and requires cost sharing for these services to be equal to or less than the cost sharing for other health care services. (Federal Mental  Health Parity Act of 2007 NAMI More on Mental Health Parity NAMI) Public Law 110–343 wikipedia.org/110-343

MHPA applies to most group health plans with more than 50 workers. MHPA does NOT apply to group health plans sponsored by employers with fewer than 51 workers. MHPA also does NOT apply to health insurance coverage in the individual market.

MHPA is a federal law that requires that annual or lifetime dollar limits on mental health benefits provided by a group health plan be no lower than the annual or lifetime dollar limits for medical and surgical benefits offered by that plan. MHPA applies to employers with more than 50 employees. For up to date information on the applicability of the Mental Health Parity Act, contact the EBSA regional office nearest you.

The MHPA does not prohibit group health plans from:

Covering mental health services within network only, even though the plan will  pay for out of network services for

  • medical/surgical benefits (although with  higher out-of-pocket cost to the subscriber);
  • Increasing co-payments or limiting the number of visits for mental health  benefits;
  • Imposing limits on the number of covered visits, even if the plan does not impose  similar visit limits for medical and surgical benefits; and
  • Having different cost-sharing arrangements, such as higher coinsurance payments for mental health benefits, as compared to medical and surgical benefits

.A visit limit coupled with a usual, customary, and reasonable (UCR) charge is not  the equivalent of an annual or lifetime dollar limit. As a result, it is not a  violation of the MHPA requirements.  Payments made by the plan on the basis of  UCR charges will vary from one case to the next.

What is not permitted is a limit  on the number of visits, together with a fixed dollar limit per visit, for example,  60 visits annually at $50 per visit (totaling $3,000), unless the medical-surgical  coverage is the same.cms.hhs.gov

 

Mental Health Parity and Addiction Equity Act of 2008

Wikipedia 

Code of Federal Regulations §146.136   Parity in mental health and substance use disorder benefits.

 

President Obama’s Plan –
Patient Protection and Affordable Care Act
Children’s Mental Health

 

 Essential Benefits Mandate of Mental Health

  • FAQ’s

May a plan impose other restrictions on mental health benefits?

 

Yes.  Plans are still able to set the terms and conditions (such as cost-sharing and limits on the number of visits or days of coverage) for the amount, duration and scope of mental health benefits. http://www.dol.gov/

Resources & Links

Consumer Resources

wikipedia.org/Mental_health_parity

Technical Resources

§ 146.136   Parity in mental health and substance use disorder benefits. Federal Code of Regulations

IRS Code § 9812. Parity in the application of certain limits to mental health benefits

Federal MHPA Renewal Legislation S.558

Go to the Library of Congress and put this information in their search screen, to learn more about any pending legislation:

Technical Links & Resources

42  USC  18022 (E) Mental health and substance use disorder services, including behavioral health treatment.

CFR 156.115 (a) (3), – Federal Provisions of Essential Health Benefits

§146.136   Parity in mental health and substance use disorder benefits.

NAMI Website
 
 
Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 Million Americans, that details how EHBs will expand mental health and substance use disorder benefits and federal laws requiring that mental health benefits be equal to, or have “parity” with, other health benefits in the individual and small group markets. .bna.com/hhs-releases-essential-n17179872551/

4 comments on “Mental Health – ACA/Health Reform Mandated Essential Benefit

  1. Editorial
    Improved Mental Health before forcing it on people

    The real problem, the audit found, is not the patients’ right to self-determination, but the failure of the state and counties to provide sufficient ongoing care and housing after the forced treatment ends. Without those services, patients end up in a dismal and destructive cycle — careening from a 72-hour “5150” hold to the street, to another mental health crisis that endangers themselves or others, and back to another three-day hold. Each new breakdown can cause further lasting damage.

    https://www.latimes.com/opinion/story/2020-08-07/improve-mental-health-care-before-forcing-it-on-people

  2. Hey Editors,

    My name is Martin and I am the CEO & Co-Founder of Cleverism.com — a leading educational website that helps people actually get their dream job (we write super actionable and helpful career guides :-).

    I stumbled upon your post on “Five stages of dealing with grief” and I thought it was very insightful.

    Over the last 2 weeks I wrote probably the most actionable and helpful guide on everything people ever wanted to know about Kubler-Ross change curve, Relevance and applications of Kubler-Ross Change Curve in Business etc.
    Change is an inevitable part and truth of life, and there is no running away from it. If change is well planned and formulated, it can produce positive results but even in spite of planning, change is hard to incorporate, accept and appreciate. This article shall throw light on the Kubler-Ross Change Curve that is the most reliable tool to understand change. The Kubler-Ross Change Curve can be effectively used by business leaders to help their workforce adapt to change and move towards success.

    In this article, we explore 1) what is Kubler-Ross Model, 2) the applications of the Kubler-Ross Change Curve, and 3) variations of change curve concepts. Any chance you’d include our actionable guide on “Kubler-Ross Change Curve” (https://www.cleverism.com/) in your awesome article (https://mentalhealth.healthreformquotes.com/mental-health/resources-mental-health/blame-fault-scapegoated/)?

    Have a lovely day and keep up the good work,

    Martin
    CEO Cleverism

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