A lot of health insurers still have many miles to go on the road to parity for consumers seeking mental health and substance abuse treatment, patient advocates maintain.
While the health insurance industry has made progress since the 2008 Mental Health Parity and Addiction Equity Act and the establishment of mental health and substance abuse as an essential benefit under the Affordable Care Act, Americans across the country are still facing barriers in affordably accessing therapists and medications, according to a report by the National Alliance on Mental Illness.
The group, known as NAMI, analyzed 84 health plans in the 15 states with the most public insurance exchange enrollment in 2014 and surveyed 2,720 consumers.
In the survey, 29 percent of respondents said they had experienced denials for mental health treatment, 18 reported denials for substance abuse treatment and 14 percent reported denials for general medical care. Among consumers in ACA exchange plans who were surveyed, the reported denial rate was lower, 16 percent for mental healthcare, but still almost twice as high as the 9 percent general medical care denial rate.
The study also found that some people have problems finding therapists and psychiatrists in their plan network--especially psychiatrists, who more and more are not taking private insurance--as well as high out-of-pocket costs for expensive medications and difficulty navigating mental health benefits prior to selecting a plan.
Locating an in-network mental health provider, results from NAMI survey:
A probe of the 84 plans' formularies found what NAMI believes are particularly worrisome trends in medication tiers.
For antipsychotics prescribed to patients with schizophrenia and other psychotic disorders, more than half of the health plans covered less than half of the major medications available in drug class. Some plans did have a comprehensive portfolio of antipsychotics, but many of them were only available on a non-preferred basis with higher out-of-pocket costs. A third of the plans listed at least half of covered antipsychotic medications on Tier 3 of their drug formularies, with higher cost-sharing than generic and preferred branded products.
Coverage of antidepressants "was somewhat better," NAMI found, with 22 plans covering at least 70 percent of the drug class. More than half of the plans listed at least 50 percent of the medications on Tier 1 preferred status, 13 plans listed at least half of the antidepressants on Tier 3 and 11 plans listed more than 20 percent on Tier 4.
For SSRIs and SNRIs, selective serotonin and serotonin-norepinephrine reuptake inhibitors used in major depression and anxiety disorders, more than a quarter of the plans covered at least 70 percent of the products. Nearly half of the plans listed at least 50 percent of the drugs on Tier 1, while 16 plans placed at least half on Tier 3, and 13 plans placed more than 20 percent on Tier 4.
The consumers surveyed were asked if they ever failed to fill a prescription for mental health or substance abuse because of the cost. Among those surveyed, 17 percent said they didn't fill fill prescriptions for mental healthcare and 30 percent said they didn't fill prescriptions for substance abuse disorders. In exchange plans, the percentage was around 30 percent. (In both exchange and non-exchange plans, a similar number of consumers said they've not filled prescriptions for physical health conditions because of costs.)
"When the cost of a prescription drug is $900 per month, as is the case with some antipsychotic medications, a 40 percent co-insurance requirement requires the person to pay $360 per month out of pocket," the NAMI report argues. "Such costs are unsustainable for many consumers and thus may serve as a major barrier to taking needed psychiatric or other types of medications."
NAMI is working with states, insurers and federal regulators to try to shorten the journey to parity. In states like New York, the attorney general has made a point of enforcing strict parity for issues like rehabilitative coverage. Excellus BlueCross BlueShield recently promised to change its practices for behavioral health and addiction treatment, and potentially cover up to $9 million in previously-rejected claims.
Going forward, NAMI recommends that insurers post up-to-date directories showing mental health and substance use treatment providers are accepting new patients, and publish standards about how mental health claims are approved or denied. NAMI is also calling on Congress and federal regulators to reduce out-of-pocket costs for mental health and substance abuse, especially for people with low incomes.
A case for investing in mental wellness With new essential health benefit rules, some insurers are starting to take a more proactive approach to mental and behavioral health.