A State Win for Access to Care

Chris’s road to wellness with a mood disorder has been long and trying. Like so many others living with bipolar, for many years, he was misdiagnosed as experiencing depression. Adding to that delay, his preferred treatment for talk therapy and medication has been denied and/or delayed by his insurance provider, stating lack of medical necessity. Appealing the claim proved just as frustrating because the insurance provider would not reveal the medical necessity requirements.

However, for many like Chris in Illinois, there was a major victory last week that brings hope that these discriminatory practices will soon be curbed.

The Illinois Department of Insurance (IDOI) announced fines totaling over $2 million for five major health insurance companies found to be in violation of the Mental Health Parity law. Illinois has been a national leader for mental health parity, which requires that mental health benefits cannot be more restrictive than benefits for other medical conditions. IDOI changed the Essential Health Benefits of plans sold on the Affordable Care Act Health Insurance Marketplace, requiring insurance companies to remove barriers to care.

All five companies agreed to take corrective action, and the Department will conduct follow up exams to ensure those companies remain in compliance

  • CIGNA Healthcare of IL
  • UnitedHealthcare
  • CIGNA Health and Life
  • Health Care Service Corporation (Blue Cross Blue Shield of Illinois)
  • Celtic

Regarding the announcement, Governor J.B. Pritzker summarized the need for this action well: “Seeking treatment for mental health or a substance use disorder is a brave step that should not be met by unnecessary roadblocks and hurdles. We will continue to lead by example and help move the country forward in achieving mental health and substance use disorder parity.”

IDOI demonstrated the following violations that resulted in fines:

  • Failing to use appropriate medical necessity criteria
  • Unnecessarily requiring prior authorization for treatment
  • Not allowing providers to request an exception to the company’s step therapy requirement for prescriptions
  • Imposing step therapy for drugs used to treat depression
  • Failing to perform proper internal testing to confirm that all plans are in parity

Chris is happy that health insurance plans are being held accountable for parity violations, but he says it is sobering to see this level of non-compliance with our state and federal laws. There is still so much work to be done.

DBSA Continues to Push for Access Across the Country

Parity is not always enforced equally for everyone. The type of insurance you have determines which agency regulates your plan. State level wins, like the one in Illinois or those in Massachusetts and California apply to people whose insurance policy is regulated by that state. Examples of state regulated policies include those purchased through the Affordable Care Act marketplace or accessed through the state’s Medicaid program.

While it is true that Medicaid is the single largest provider of mental health services, more than two-thirds of Americans receive their insurance via a private carrier: Fifty-five percent of those policies are employer provided health plans, which are often regulated by the US Department of Labor (DOL).

Last week, DBSA had the opportunity to comment on proposed updates to DOL’s 2020 Mental Health Parity and Addictions Equity Act (MHPAEA) Self-Compliance Tool from the perspective of the more than 23 million people throughout the United States living with mood disorders.

Having an internal compliance plan can help improve insurance companies’ compliance with the law and reduce potential MHPAEA violations. The tool helps plans prevent, detect, and resolve issues as they arise. Successful compliance plans share the following characteristics:

  • Training and education
  • Internal monitoring and reviews on a regular basis
  • Prompt response to offenses and corrective action

DBSA made the following recommendations to strengthen the MHPAEA Self-Compliance Tool:

  • We recommend that plans be required to educate participants, so they know their rights. DBSA provides educational materials, like the webcast found at this link that inform peers of their rights.
  • We encouraged DOL to establish minimum timelines for how often insurers are expected to conduct internal compliance reviews and for appropriate prompt action when a plan discovers a violation. This should include providing retroactive relief and notice to potentially affected participants.
  • We also support internal consumer ombudsmen programs to assist peers in navigating their benefits and elevating their complaints of noncompliance.

DBSA supports improving the implementation and enforcement of MHPAEA through the Self-Compliance Tool. Equitable access to a full continuum of mental health treatment services must be an essential component of health care coverage on par with other medical conditions. DBSA stands ready to serve as a resource to DOL in achieving parity, which will improve health outcomes.

Your voice can make a difference

DBSA is currently advocating for state and national policies around access to mental health services. As a DBSA advocate, you play an important role in communicating with your state and federal legislators about the important needs in your community. Stay tuned for targeted communications to let them know how your family and others are being impacted and call on them to ensure that access to mental health coverage is seen as a right and not a privilege.

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