Many States are Adding Ombudsmen to Ensure Legal Access to Mental Healthcare

Like many other people, Ryan did not know where to turn to file a complaint about the decision of his health insurance to deny coverage of treatment for a mental health condition. He felt lost. Ryan is not alone in this. According to the Kaiser Family Foundation, more than a third (34.3%) of adults with serious mental health conditions in the U.S. did not receive treatment in 2018, many of them for the same reasons as Ryan.

In several states, for peers like Ryan, there is an Ombudsperson, an individual designated for assisting in accessing Behavioral Health Care.

The Ombudsperson serves as a neutral party, acting independently, to help consumers resolve behavioral health care access and coverage issues. They also identify, track, and report concerns, complaints, and potential violations concerning the availability of, and terms and conditions of, benefits for mental health conditions.

The responsibilities of the Ombudsperson include providing appropriate information to help peers obtain mental healthcare, including peers who are uninsured or have public or private health benefit coverage. They assist insurance beneficiaries and healthcare providers in reporting concerns and filing complaints with appropriate regulatory or oversight agencies relating to treatment limitations, such as:

  • Number of visits covered;
  • Amount of reimbursement per visit;
  • Equity of medical necessity criteria.

Depending on the state, the Ombudsman submits a report each year that includes information concerning actions taken to address complaints and potential violations to the appropriate regulatory agencies. In many states, that annual report is posted on a public website for anyone to review. This report must comply with all state and federal confidentiality laws by not including in the report any personally identifying information about individual consumers or health care providers.

Turn Your Lived Experience to into a New Career

An Ombudsperson is a professional advocate, but there are many other professionals who also serve as advocates. In the time of this pandemic, many people are looking for a way to use their existing skill sets and professional experience to find a new career path. By way of example, at the end of July, the unemployment rate was 11.0 percent. Although she made her transition prior to the pandemic, Kimberly’s story illustrates just such a move.

Standing on the steps of the Texas State Capitol having just heard herself say, “I’m Kimberly, and I live with bipolar disorder,” she was then asked by a television reporter how long she had been openly sharing her experience with the world. Kimberly looked at her watch and responded, “about 5 minutes.”

The next day, the story was printed in the newspaper in Kimberly’s hometown. She felt concern immediately. Her family came to mind; what would they think? Then, she thought of her professional role in the health insurance industry. Would someone discover the article and try to push her out? But then, she thought of her dad and his last words, “Remember to say that I died due of stigma.” He was a doctor and had bipolar, too, and died of complications due to alcohol use disorder.

Up until this point, Kimberly had not previously been open, nor public, about her experience of bipolar disorder, yet from that moment on, she “kept saying yes” to opportunities to share her story, from the Texas legislature to Hogg Foundation for Mental Health to researchers at University of Texas, Harvard Pilgrim, and Harvard Medical School. She has always had a dream of becoming a researcher, and now, partly through her advocacy with DBSA coupled with professional experience, she has become a private consultant advising industry and academic researchers on patient-centered outcomes to pursue and engage other peers.

In this global time of transition, many people just like Kimberly are using their lived experience and professional experience to become an advocate and maybe even find a new career. There are many ways to combine past professional experience and the lived experience to embark on new and fulfilling professional journey. Becoming a peer support specialist, as highlighted in previous articles, is just one example of that. However, the first step could be as simple being willing to tell your story.

As Kimberly put it so well, “When I stepped forward to participate in advocacy, it changed my perspective, my perception of myself, my philosophy, the language I use to describe myself. It changed everything for me.”

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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