Insurance Coverage of Mental Illness

With a nation still mourning the Newtown mass shooting and on going concerns of what appears to be an epidemic currently taking place in our country, now more than ever before, mental illness is being discussed and addressed as a serious issue.  While the conversation may start with the causes and factors that may lead to such insipid crimes and mental instability, we'll never be able to prevent all mental illness. It's a complex, long term problem that will take years and years of study and reform in how we think and operate as a society.  For the immediate future, the quickest and easiest fix for those with mental struggles is to consider improving treatment through proper care and insurance coverage.

For too long, the health insurance industry has virtually ignored the pressing need for increased coverage and access to mental health care.  One of my Claims Security of America client's who's self employed, and maintains a traditional individual policy through Blue Cross Blue Shield of Florida, has mental health coverage that only allows for 8 visits to a Psychiatrist or Psychologist a year. 8 times in 365 days! That's hardly enough time for any sort of real treatment or help should he need it. What makes even less sense if that he was under a group's insurance plan with more than 50 employees which covers mental illness and treatments, then he'd have no coverage limits as required under the Mental Health Parity and Addiction Equity Act.  Naturally, insurers profit more from indemnifying a group verse an individual; but you could argue a self-employed person is under far more stress and more susceptible to mental health care than someone who's in a full-time position with full-time benefits, and thereby needs the extended coverage even more.

In 2008 Congress passed the Mental Health Parity and Addiction Equity Act, which went into effect Jan. 1 of 2010, but this set of laws still only affected group health plans with more than 50 employees.  Under this law, insurance companies can no longer arbitrarily limit the number of hospital days or outpatient treatment sessions, or assign higher co-payments or deductibles for those in need of psychological services. However, the single self-insured is one again left out. http://www.apa.org/helpcenter/parity-law.aspx# 

Unfortunately, when the recession hit a few years ago, many states and communities made significant mental health care cuts.  ABC NEWS reports:

"Since the recession forced budget cuts in 2009, state general funding for mental health care has decreased by an estimated $4.35 billion nationwide, according to the National Association of State Mental Health Program Directors . . . "

According to The National Institute of Mental Health more than 54 million Americans suffer from sort of mental disorder in any given year. That's roughly 1 in 4 of us. One in 17 people suffer from a "serious debilitating mental illness." An authoritative 2005 study suggested more than half of all Americans, will at some point, experience a major psychiatric disorder or substance abuse in their lifetime. In short, mental instability is the most common struggle we face.  Here's some warning signs to look out for and how to cope with them.

http://www.nmha.org/go/information/get-info/mi-and-the-family/recognizing-warning-signs-and-how-to-cope

Beginning in 2014 the Affordable Care Act (Obamacare) will require that all health insurance plans for small employers (less than 50 employees) and individuals include coverage for mental health and addiction.  Also, states that agree to expand Medicaid under the ACA will make the federal health insurance program's mental health coverage available to more low-income people. In addition, the ACA allocates money to increase the number of mental healthcare professionals across the country. The New York Times offers more detail on Obama's expansion of mental health care.

http://www.nytimes.com/2012/07/10/health/policy/health-care-law-offers-wider-benefits-for-treating-mental-illness.html

Help is on the way, but much more is still needed.  The World Health Organization ranks depression as the world's leading cause of disability. And if you've ever been even slightly depressed, you're well aware of how paralyzing it can be. Until we, as a society, accept mental illness as a disease every bit as life threatening as cancer, real progress will never be made

We know Congress has a full plate already, but nothing is ever solved overnight. Mental health is finally getting the attention it warrants and let's hope we begin to see benefits that work for all of us, not just some of us.  Parity means equal coverage for both mental health and physical health conditions.  Discriminating between group coverage greater than 50 employees, other small groups under 50, as well as individuals, does not conform to the definition of parity. But as long we continue to engage in these kind of discussions,  hope for a better future for all of us seems brighter.

Stay Positive, Stay Informed, Stay Healthy
- The Patient's Advocate

Rising Health Care Costs and Insurance Premiums

Now that the Affordable Care Act (ObamaCare) is here to stay a lot of us continue to wonder how our current care and costs will be affected. The health care industry is a $2.8 trillion business.  Health Care  in the U.S. accounts for almost 20% of the Gross Domestic Product and nearly 25% of the Federal budget. 

As for your personal care, the vast majority of us will not see any significant changes in how we're treated, which providers we can see, or what these services will cost out of pocket. If anything, there will be even more choices available in coverage and care. However, with these additional opportunities there may be a slight initial increase in our premiums.

Anthem Blue Cross of California recently stated it will seek to raise individual policy holder's premiums by an average of 18%.  http://www.latimes.com/business/la-fi-insurance-rate-hikes-20121128,0,1885711.story

That's a pretty hefty increase, but before you get too concerned about it you should now any rate changes are subject to an intense government study and approval; which is one of the more important mandates under the Affordable Care Act.  http://www.healthcare.gov/law/resources/reports/rate-review09112012a.html 

In November of 2014 California will have a chance to vote on whether or not the State's Insurance Commissioner can overturn any premium increases deemed "too excessive" and will be able to order Insurance Companies to refund this money to its subscribers. Plan on other states to follow suit as the government continues to regulate the Health Insurance industry and favor the patient. 

You can also contact your State's Insurance Office now if you feel your premiums are being raised without cause or merit. Do not let private-for-profit corporations just roll over you. As a subscriber, you have more rights and choices than you think. Increased regulation is here to stay.   Controlling the cost of health care is a challenging endeavor. Providers, insurance companies and subscribers each have an interest in a more cost effective and efficient health care delivery system. 

Subscribers should take the time to become more educated about all the options soon to be available. An estimated 30 million more Americans will finally be able to purchase health insurance through the Affordable Health Care Exchanges. That's a lot of new participants in a system that's already plenty complicated and diverse.  See our previous blog entry on Health Care Exchanges for more information:
http://thepatientsadvocate.blogspot.com/2012/11/health-care-exchanges-and-affordable.html

One step in simplifying the maze of insurance land would be for insurance companies to develop and publish a standardized ratings criteria on the various providers they cover so patients can make objective choices based on their specific needs and requirements. Many customer service based industries like hotels, already implement ratings systems for their properties. One of the goals of the Affordable Care Act is to make the Health Insurance industry more transparent and publicly challenged.

Provider reimbursement is yet another area where reform is necessary.  Insurance companies can start by changing the current "fee for service" system which only encourages more services instead of efficiency and  improved care. In other words, no incentive is given to treat a patient effectively and timely because providers automatically earn more, the more services they perform.

Cost of care is generally a combination of price and use of services.  Insurers and Providers can easily control price. Providers have a mind set of "the more I do, the more I get paid."  One idea suggested by Blue Cross and Blue Shield of Massachusetts is a "global payment" approach, an alternative to the traditional fee for service system. Providers, including hospitals and physician groups, are placed on a fixed budget for reimbursement.  Their end financial payout is performance based upon whether or not they meet the initial target budget. HMO's tried a similar payout method years ago with capitation reimbursement.

Under the target budget approach providers are free to perform any services they deem "medically necessary."  The insurer will not interfere with the medical decisions made by the provider.  If the provider group comes in under budget, they are then rewarded with a share of the savings.  If they come in over budget, they agree to absorb part of the losses. To prevent providers from providing too little service and coming in under budget at the expense of providing need care, the insurer has put in place bonuses tied to achieving quality of care measures.  Such measures would include a certain percentage of patients who have high blood pressure under control or who have maintained appropriate cholesterol levels.

Another feature of the Affordable Care Act meant to reduce health care costs is the 80/20 rule.  Under this rule insurers must spend at least 80% of premium dollars on health care benefits. If they fail to maintain this percentage they must provide refunds to subscribers.  The rule provides an incentive for insurance companies to manage their administrative expenses and maximize premium dollars toward benefits, yet another protection for subscribers.

Insurance companies can complain all they want now about their rising costs or percentage of dwindling billion dollar profits, but by the time ObamaCare is in full effect in 2014, there will still be plenty of money to be made on their behalf.  However, the single biggest beneficiary of the new nationwide system is clearly you and me.  Don't let the insurance companies and special interest groups manipulate the truth with claims of "Socialized Medicine" and "Death Squads." In the long term, patients will clearly be better off with more affordable and quality health care because of the reform set by the Affordable Care Act. When it comes to health care in this country, the U.S. government has our backs now, more than ever.

Stay informed. Stay positive. Stay healthy.
- The Patient's Advocate
   medicalclaimsfilingexpert@gmail.com