Insurers Can Restrict a Patient’s Mental Healthcare  (11:35)

It can be really hard to get mentalhealthcare in the U.S, even if you find a therapist in network.

Broadcast Retirement Network’s Jeffrey Snyder discusses the insurance approval process for mental health treatment with The Kennedy Forum’s Lauren Finke.

Jeffrey Snyder, Broadcast Retirement Network

This morning on BRN, insurers can restrict a patient’s mental health care. Joining me now to discuss this and a lot more, Lauren Finke is the Senior Director of Policy at the Kennedy Forum. Lauren, it is so great to see you.

Thanks for joining us this morning.

Lauren Finke, The Kennedy Forum

Thanks for having me.

Jeffrey Snyder, Broadcast Retirement Network

Yeah, and we’re going to talk about mental health and more importantly, how insurers accept or not accept mental health payments. Mental health, Lauren, is a big challenge for our country. I think I read stories about it every day in various pieces in the press.

This is a big deal.

Lauren Finke, The Kennedy Forum

Absolutely. I think also the larger amount of coverage that mental health has been getting over the last few years has, I think, made this even more important and useful to people as they kind of have a better understanding of what’s going on and what sort of their rights are and they’re entitled to. This is also great timing, I think, for the general public to know these things.

Jeffrey Snyder, Broadcast Retirement Network

164 million Americans have some form of either employer-based health insurance that they buy through the exchanges, but there isn’t really parity. I want to ask you, is there parity at least in terms of how across the states, across our union, about how insurance companies allow or disallow mental health services?

Lauren Finke, The Kennedy Forum

Yeah, I mean, the answer is no. I think it’s very evident from the second that you pick your health insurance out, how going through that process is really confusing at basically every set of people. You don’t really know exactly what your insurance covers.

You get reams of paper documents sent to your house or emailed to you, and you’re kind of looking through it trying to find coverage requirements or the things that you have been given, and it’s really impossible. It’s hard for me to find, and I work in this field and read these things all day long. So if that’s what the initial consumer experience is, as soon as they start even looking at their documents, it’s like that all the way through trying to get care, trying to continue to receive care and pharmaceutical benefits and all the things, and so it really is not an even playing field and really shrouded in a lot of opaque practices and confusion that’s sort of meant to whittle out what the consumer can do for themselves and even frankly what providers are able to do and navigate for their own patients.

So it can be very difficult for everyone, and a lot of that is because each product is so different, and the health plans kind of have that as something that benefits them for people not to exactly know what they’re getting themselves into or what their rights are.

Jeffrey Snyder, Broadcast Retirement Network

Sure. So pay your premiums on time. If not, we’re going to have your coverage lapse, and we’re not going to tell you exactly what your coverages are, at least in a clear and transparent way.

When it comes to mental health and the various insurers, obviously insurance is regulated at the state level. Who determines what mental health services Jeff Snyder gets versus what you get or someone else may get, depending on the provider?

Lauren Finke, The Kennedy Forum

So some insurance is regulated by the state regulators. Others is regulated by the federal government, and so that is also complicated because if you are trying to appeal something, sometimes you don’t even know who regulates your own insurance, and that’s another complicated factor. So that is a big component, and then what gets put in your product is sort of dependent on, it could be also dependent on your employer.

If your employer is self-funded, then they may be able to have a little more control over what goes into your product, but your employers also say you’re working for a Fortune 500 company, they may not know all the ins and outs of what is required or medically necessary, and so making sure that those planned documents and things are, and the products that people are getting are equal across the board can be tough.

I think that’s why some of the new parity rules that are coming on board to sort of allow for an equal playing field, if implemented to fidelity. I think that the big if there is making sure that, okay, now we have all the groundwork laid, and now moving into a time you sort of enforce that through what the coverage that people are getting, functionally getting, is not just on paperwork. So whether you’re able to go out of network and get in-network rates when you can’t find in-network care and your insurer can’t find someone to cover that, and so the rights that you have within that are the rights you have to, when you’re looking through your plan directory and making sure, we call them ghost networks, that you’re not just, you know, going through reams and reams of phone numbers trying to call someone that’s taking appointments, right, all those things that we kind of think of, of like historic, like everyone’s been through them barriers, those are sort of things that are pretty connected to what is included in health plan coverage, and you’re right, it is a lot of times it is covered by the state regulators and or insurance, federal insurance, the federal regulators.

So we’ve got kind of two things happening at the same time, and that makes it complicated for consumers to navigate to.

Jeffrey Snyder, Broadcast Retirement Network

So how do we, you talk about parity, how do we get there? Is it legislative? Is it regulatory?

Is it regulatory at both the federal and state level? I mean, it just seems like if you buy a policy, first of all, you should know, you should be able to tell what’s in your policy, what the coverages are, that’s number one, I would think, again, a layperson, and number two, everyone should be able to get the same services if they have an issue such as a mental health challenge, or they need to see a primary care physician.

Lauren Finke, The Kennedy Forum

So I think the answer is both, and then also an and in there, I’ll start with the and, which is that, you know, a lot of people have like insurance, like in their coverage documents, it’ll say your mental health is covered, here are the things that are covered. And then they run into barriers getting that care. And so there are, you know, things that consumers can do to sort of empower themselves, it’s complicated, right?

And especially if you’re going through like, especially mental health, or like substance use disorder crisis, you may be in less of a state than someone who’s like broken their arm to try to like sit on the phone and fight with your health insurer about some of these things. But there are, you know, rights in place that everybody has, as part of their health insurance. And so you go to the regulators when you are trying to appeal, basically what you think is a wrong decision or a denial or a delay in care, or you may be getting the runaround and getting an answer from your health plan.

So I guess I’ll say I’ll start with everyone has a base level of like rights they are entitled to the Federal Parity Act applies to many people and plans, and basically ensures mental health and substance use disorder coverage requirements are equal to what is provided on the medical surgical side. Of course, the medical surgical side of healthcare is not renowned for being like the easiest thing in the world to navigate either. And there’s still practices that you don’t necessarily want to in the land of what, you know, what that access looks like.

I think there’s additional components that we would consider, you know, parity relevant, but also like mental health and consumer protections that states in particular can do. So I’ve done a bill in California that went into law in 2021. And that bill, we consider that like a mental health and substance use disorder, like bill of rights, almost where it’s like you are entitled to medically necessary mental health care.

Your insurer doesn’t get to say what’s medically necessary based on their own proprietary criteria. They have to decide what’s medically necessary in the same way that your clinician would, which is by using nonprofit clinical standards of care. So for example, if I’m trying to seek treatment for substance use disorder, the American society of addiction medicine is what that decision would be based off of.

So there are things that states can do through legislation, but there’s also other things too, that they can do. Not the legislation regulators do have a lot of authority to do things, or, you know, governors can implement things right away too, to sort of put these protections in place. So in California, that particular bill became our model bill that we use at the Kennedy forum has been replicated in other states.

So Georgia, Illinois, New Mexico have all had versions of that go through. And we think of those as really good supplementary bills that sort of get at the heart of what some of the federal parity legislation is also meaning to do. So it’s not that other states can’t do some of that stuff, but it does make it a little bit easier for state regulators to then go and regulate on that and work with health plans to make sure that what’s in their coverage documents is full and comprehensive and really connected to clinical standards.

Not a lot of like, you know, we sort of hear of like the industry making money for themselves or all of these things. I think people who are pretty skeptical of, rightfully skeptical of what kind of quality healthcare that they’re getting. I think that this state legislation and some of the federal mechanisms that we’re seeing happen more and more are really focused more on the consumer and less on like putting the burden on them to go through an appeal to fight their health plan one-on-one.

I think some of the like, you know, most amazing stories we’ve heard of people successfully getting healthcare coverage after getting denied it a ton are like parents of kids who are, they’re just like really trying to fight for this treatment for their 17 year old or something. Right. And that requires so much time and energy and knowledge of a system.

And so the new rules that are coming on, well, I guess that came out this week, you know, are really aiming at trying to automate that process so that it’s not on the consumer, it’s on the plans and the regulators to work with each other to figure out a transparent system that’s workable.

Jeffrey Snyder, Broadcast Retirement Network

Yeah. Or else it becomes like a Rube Goldberg. Who has the time, as you said, to hand the resources to kind of navigate that.

Lauren, this is an important topic and one that I think we’re going to be covering ongoing. We thank you so much for joining us and we look forward to having you back on the program again very soon. Thanks so much.

And don’t forget to subscribe to our daily newsletter, The Morning Pulse for all the news and lifestyle wellness. So much more details at our website. We’re back again tomorrow for another edition of BRN.

I’m Jeff Snyder. Stay safe, keep on saving and don’t forget, roll with the changes.