While the pandemic has put everyone’s
According to the CDC, 44% of high school students reported persistent feelings of hopelessness and sadness, while emergency department visits for attempted suicides increased by 51% for teen girls and 4% for teen boys since 2019. And yet, health insurance companies have faced scrutiny for denying mental health treatment claims at alarming rates. Even before a pandemic surge, a 2014 CBS 60 Minutes Sunday report revealed a claim denial rate of over 90% by Anthem.
John Joseph Conway, a national employee benefits attorney and founder of J.J. Conway Law, considers these findings incredibly troubling, but unsurprising. He works with families to help obtain coverage or reimbursement from plan sponsors for teens seeking extended mental health treatments for conditions like eating disorders, self-harm and substance abuse.
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“Most insurance plans do provide mental health benefits and are supposed to be provided on a pretty broad scale under law,” says Conway. “Where the problem arises is when insurers' interpretation of their contracts become overly restrictive.”
However, restrictive interpretation of mental health coverage is technically against federal law — namely, the Mental Health Parity and Addiction Equity Act of 2008, which required that access to mental health and substance use disorder services is comparable with access to medical and surgical services.
“This meant that plans can no longer choose to cover only some type of mental health and substance abuse treatments if the same plan covered comparable medical and surgical treatments,” says Dr. Lawrence Weinstein, chief medical officer at American Addiction Centers. He notes that the parity act required health plans and insurers to have comparable treatment across categories like emergency care, prescription drugs, in-network and out-of-network care and residential treatment, as well as comparable co-pays, deductibles, out-of-pocket maximums and reimbursements rates.
Fourteen years later, the Mental Health Parity Act has not delivered on its promise when addressing behavioral health treatment needs. This year, the Department of Labor, Health and Human Services and the Treasury reported that none of the health plans or insurers they reviewed for compliance with the parity act passed.
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“The law was there, but enforcement had not been applied,” says Dr. Weinstein. “The health plans did not raise their hands and volunteer to do it.”
Beyond a lack of enforcement, there is a persistent issue of prioritizing cost over care, Conway says. That value judgment can have catastrophic effects.
“Mass denial of claims for substance abuse, eating disorders and generalized mental health issues are affecting the teenage population,” says Conway. “But from the insurance’s perspective, it’s just extremely expensive care.”
Conway sees claim denial as particularly prevalent when a teen needs to be admitted to a residential treatment facility, which without coverage can cost anywhere between $10,000 to $60,000 per month. Many plans actually require pre-authorization for the admission into treatment facilities — meaning the insurer or plan must deem the service medically necessary, and hence covered. Unfortunately, in Conway’s experience, many of these requests are denied.
Once the patient is within a treatment facility, they often have to continue to prove that they are a threat to themselves or others to remain covered by their health plan, explains Conway, who views this stipulation as another violation of parity.
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“If someone is put into a nursing facility, the idea is to get them better so they can return home and live independently,” he says. “These treatment facilities are also supposed to be getting their patients well enough so that they can go back home and no longer present a danger to themselves or others.”
Conway predicts that if insurance companies continue to not take the Mental Health Parity Act seriously, there will be a lot of class action litigations regarding mental health benefits and coverage, along with further state-wide regulations.
Conway points to the 2019 case Wit V. United Behavioral Health as a prime example. According to the plaintiff, David Wit, UBH developed restrictive guidelines for coverage determinations and prioritized cost savings over members’ interests. Wit won in the U.S. District Court for the Northern District of California, and UBH was ordered to notify approximately 60,000 families that their claims needed to be reassessed. However, UBH appealed and the Court of Appeals for the Ninth Circuit overturned the district court’s decision this year. Notably, Anthem Blue Cross Blue Shield of Wisconsin is currently involved in a similar case.
“This is a very unique issue in the sense that is overwhelmingly nonpartisan,” says Conway. “Substance abuse problems and mental health issues affect people across the board.”
For Dr. Weinstein, the population health of the entire country is at stake if health plans cannot expand their mental health coverage.
“Patients that can address behavioral health conditions and substance use disorder early on will have better outcomes,” he says. “Their quality of life and total medical course will be affected by that.”
