Mental Health Symptoms

Mental Health as an essential benefit under ACA Health Care Reform 
Parity Laws – Mental Health must be equal to Medical Benefits

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Mental Health

is an essential mandated benefit under ACA/ObamaCare/Health Care Reform

All Insurance plans –  qualified health plan (Obama Care compliant-meeting the 10 essential benefits) must provide parity – equal coverage for mental health and substance use services resulting in no added treatment limits and no extra costs.

More than 43 million Americans suffer from depression, anxiety, and other mental health conditions. 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, like 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.

Hopefully, the ACA mandate and parity laws will help remedy the problem.

Information, links and resources

 

988 for Mental Health Emergencies

Mid July 2022 there is supposed to be a new # to call, just like 911 for Mental Health Emergencies, but the funding doesn't see to be there for California.

#California Mental Health Insurance Parity

Summary:

AB 88 CA Insurance Code §§10144.5.  Health and Safety Code§1374.72  requrires that severe mental illness for children be covered and also 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.

AB 88 also requires Insurance Companies  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

SB 221   Return Visit Guarantees 

SB 221   requires that Mental health and substance abuse patients be offered return appointments no more than 10 days after a previous session, unless their provider OKs less frequent visits. CA HealthLine  *  CA Health Line 11.24.2021 *

Severe Mental Illness Coverage
AB 88 – 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 [these diagnosis]:

(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 …

Mental Health Parity at a Crossroads

California Law Aims to Strengthen Access to Mental Health Services

SB 855 2020 
#Substance Abuse Treatment

SB 855 requires insurance companies to expand the definition of Mental Health to include Substance abuse and cover as any other illness.   Learn More — Bill Summary

Insurance Code 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 … 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.

Plans must  cover out-of-network services based on billed charges (rather than a discounted allowed amount or negotiated price) immediately if the plan was not able to provide in-network services in a timely manner based geographic access and timeliness requirements. CA Health Line *

Links & Resources

FEDERAL – Mental Health Parity and Addiction Equity Act of 2008

Mental Health Bill of Rights

 

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

Resources & Links

Specimen Individual Policy #EOC with Definitions

Employer Group Sample Policy

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy with Definitions

VIDEO Steve Explains how to read EOC

Videos by Steve Shorr

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

  1. If one is mentally ill, has Medicare and Medi Cal, is constantly in and out of inpatient care, will Medi Cal pay if Medicare doesn’t as the person maxed out his inpatient days and used up the lifetime limit?

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