How the New Ruling on Mental Health Coverage Affects Us All

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Following the school massacre in Newtown, Connecticut, last December, President Obama vowed to expand access to mental health care in an effort to reduce gun violence. Earlier this month, the Obama administration released long-awaited rules to ensure that people with mental illness or addiction issues receive the same health insurance coverage as those with physical ailments. The rules represent the final implementation of the Mental Health Parity and Addiction Act, which was signed into law five years ago. Carol McDaid, co-founder of Capitol Decisions, a consulting firm that specializes in substance abuse policy, led a coalition that supported passage of the law. McDaid, a recovering addict herself, has been working since 1986 to get parity legislation passed.

Carol McDaid

We spoke with McDaid to find out how the new rules could affect people with mental health and addiction issues, their potential impact on gun violence and her advice for consumers fighting denied health insurance claims. What follows is a lightly edited transcript of our conversation. 

Karin Kamp: Can you start by explaining what the final mental health parity rule means?

Carol McDaid: The law is intended to equalize the treatment of addiction and mental illness with other health conditions covered under a health plan. The majority of states have parity laws, but this is a federal one. It applies to the new health insurance exchanges and individual and small group plans, especially in the individual market, that have been more likely to limit or not cover addiction and mental illness at all. The federal rule is important because it expands the number of people that will get parity protections and, for the first time, it covers the medical management techniques that [insurance companies] use to limit access. This final rule says that health plans or payers cannot apply these kinds of medical management techniques in a different, more stringent way than they do on other medical conditions that they cover.

This game of “whack-a-mole” is common with health insurance plans: One issue gets fixed and then they clamp down elsewhere.

Kamp: What’s an example of a medical management technique?

McDaid: An example that we saw quite frequently would go as follows: The health plan, on the medical side, would approve, say 10 outpatient visits [for] physical therapy at one time upon receiving indication from a doctor that this physical therapy was needed.

But when it came to approving outpatient mental health visits, once the interim rule went into effect in February of 2010, we were finding that prior authorization was being applied more stringently: Every single visit had to be authorized.

Kamp: How would something like that affect patients?

McDaid: So now, the patient, instead of having to get their counselor or their psychiatrist to fight with the insurance company to get reimbursement for every single visit, plans that approve 10 visits for physical therapy would have to approve [the same number] for addiction or mental health outpatient counseling, as well.

Kamp: Are there any specific groups that you think are going to be especially helped by this?

McDaid: Patients that need this care are one of the big winners. There were a number of states that were limiting access to addiction rehab in their benchmark benefits, creating a momentum that maybe this whole level of care shouldn’t be paid for anymore. This game of “whack-a-mole” is common with health insurance plans: One issue gets fixed, and then they clamp down elsewhere. By 2010 we saw plans were reducing peoples’ out-of-pocket spending and increasing access to outpatient care. But we then saw more limited access to intermediate levels of care, like intensive outpatient, partial hospitalization or residential care. One of the big victories in this final rule is that it says if a plan offers intermediate levels of care for medical conditions with specific examples such as skilled nursing facilities or stroke and cardiac rehabilitation centers, then it will also have to offer addiction and mental health residential services. This was a very important victory because we were continuing to see exclusions in policies that limited that level of care or just excluded it altogether.

Kamp: Will these new rules have an impact on gun violence?

McDaid: I think they have the capacity to. But the final rule does not apply to three groups — Medicaid-managed care, the Medicaid Expansion population and CHIP [Children’s Medicaid]. If we don’t end up applying it in those populations, I think its capacity to curb gun violence is reduced.

Kamp: Do you think this will help veterans returning from war?

McDaid: I absolutely do. Veterans are returning from Iraq and Afghanistan with higher levels of mental health and addiction problems than we’ve seen in history. And because of that, there’s been a rush of veterans seeking health care. Increasingly, we’ve relied on National Guard and reservists to serve and when they come back they have to rely on the health care at their jobs. I think that the smart money is going to be doing specific outreach to let [veterans] know, hey, we can get you in and see you right now.

They have battalions of lawyers right now scurrying to figure out how they can get around this rule and they will try new techniques to limit access to care.

Kamp: Do you see any problems in implementing this final ruling?

McDaid: When an industry has been doing things a certain way for 20 years like they have been managing behavioral health benefits, it’s like turning the Titanic around. They have battalions of lawyers right now scurrying to figure out how they can get around this rule and they will try new techniques to limit access to care. So there will have to be a continued orchestrated response not only from addiction rehabilitation programs — who are the big winners in this — but also from all aspects of the mental health field to file complaints when they see compliance problems with the law. [They need to] speak up, teach their staff how to help the patient ask for both the medical and the behavioral health benefit when they’re verifying benefits so they can compare and see if their plan is out of compliance. It’s not like this passes and a spigot turns on and benefits just start flowing. It doesn’t work like that.

Kamp: Do you think that this ruling may help minimize the stigma for both addiction and mental health services?

McDaid:  I certainly hope so. I’m in recovery myself from addiction and the stigma is incredible. I split my time between DC and Richmond, Va., and when I tell people in my neighborhood in Richmond that I’m a recovering addict, you can kind of see them start backing up — like they might catch it or something. And there are a couple of things in the Affordable Care Act, that (even though this rollout has been abysmal) if implemented, “medicalize” these illnesses. By providing treatment for them, the hope is that it will become mainstreamed into primary care. Now it’s on advocates like me to go and run the ball down the field. But all of us have to say — if you or a loved one needs it — go seek this treatment. And especially for parents of kids [who] look the other way, it’s kind of like shame on them, if they don’t take advantage of it.

On addiction, our silence is killing us.

Kamp: Is there anything else you’d like to add that could help people?

McDaid: There is a level of patient responsibility to this. It’s really important for individuals, moms, dads, working people to realize that if you don’t appeal when you have a denied claim, if you don’t go to your human resources person and say, “You know what? I’m paying premiums for this and I’m not getting anything from it. You’ve got a summary plan document that says this stuff is covered and suddenly when I or my family member need it, lo and behold, it’s not covered,” then nothing will change. [There is a parity appeals tool kit available to help with the insurance company appeals process.]

People are scared to tell their employer that they or someone in their family needs these benefits. If this was something to do with breast cancer, they’d have organized a sit-in or a “call-in-sick” day — but on addiction, our silence is killing us.

Karin Kamp is a multimedia journalist and producer. She has produced content for, NOW on PBS and WNYC public radio and worked as a reporter for Swiss Radio International. She also helped launch The Story Exchange, a site dedicated to women's entrepreneurship.
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