Officials discuss effects of ACA on behavioral health insurance - WOWK 13 Charleston, Huntington WV News, Weather, Sports

Officials discuss effects of ACA on behavioral health insurance

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There are several aspects of behavioral health, and some officials are debating whether insurers are doing enough or will be doing enough under the Affordable Care Act to cover the full spectrum of these disorders.

Bill Freedman, a partner of Dinsmore & Shohl's Cincinnati location, explained there have been several steps taken since the Wellstone Parity Act amendments to address behavioral health insurance coverage.

However, David Clayman, a clinical and forensic psychologist at Clayman & Associates, says more needs to be done in the insurance arena to focus on the full person, not just the pills they take.

In the Wellstone Parity Act, Freedman said if a plan is covered by the act and the plan offers medical surgical benefits, then it has to offer those same types of benefits to the mental health and substance abuse areas.

"They couldn't discriminate. They had to use the same medical management techniques. If the plan was covered by the Wellstone Act, they had to treat behavioral health disorders in the same fashion as medical surgical complaints," Freedman explained.

However, this act did not apply to individual coverage or small group plans, which would be plans for employers with fewer than 50 employees. It also would not cover non-federal or governmental plans, he said.

Freedman said although the Wellstone Act only covered large groups, some states have offered coverage to small group markets.

"It may not have been up to parity requirements," he added.

Then, there was the Affordable Care Act, which addressed the individual and small group market, Freedman continued.

"Whether on the new state exchanges or off them, the plan must offer what are known as qualified health plans. It also has to offer essential health benefits, which includes mental health, substance abuse and behavioral care," he said.

This takes effect in 2014, and the state's benchmark will set the standard. In West Virginia, that benchmark is Highmark.

Freedman explained that the benchmark chooses the minimum and other plans in the states follow its lead. So, if the benchmark chooses to cover three types of drugs, individual and small group plans must cover three drugs, but they don't have to be the same exact drugs.

"They would use the same approach to medical necessity and cost to other drugs," Freedman said. "The likelihood that the plans have a formulary that has no behavioral health drugs is zero. All commercial plans in large group market place are sure to cover behavioral health drugs because it's a lot cheaper if they have a health disorder to spend little time in front of a doctor."

Then it comes down to what is medically necessary.

"It's perfectly permissible under the Wellstone Mental Health parity rules to use reasonably medical management for approving care," he said. "You can't use standards for mental health that are different than the standards for medical surgical."

Insurers can decide reasonably clinically approved treatment guidelines, and Freedman said they have to look at what are "respected treatment methodologies."

Clayman, however, says mental health coverage has been subject to discrimination in the past.

"The sad thing that has happened nationally is that behavioral health has been medicalized," Clayman said. "You pay for medicine but not for psychotherapy or make it very burdensome where you don't pay for social support. That's only funding one portion of what's going on. There's such limitation that it's hard to take care of the whole person."

Clayman said similarly in the private sector, there are limitations to the number of sessions, and paperwork is "intrusive and burdensome" to the patient.

"If you want to get mental health services, I have to justify seeing you. And the one in control of payroll health moneys limits you often to one psychotherapy session a week," Clayman said. "When someone is at crisis, they need more frequent contact and it's difficult, if not impossible, to get coverage and get approved to see them three time s a week to prevent them from going to the hospital."

Freedman said there is much debate about psychotherapy versus medication.

"There's a great deal of discussion in literature of when and under what circumstances talk therapy is a true medical cure or merely quackery," he said. "This provides a window into that dispute."

"Are we overmedicating people on some of the less severe areas, or would the more expensive group counseling work better? People may differ on that," Freedman added. "Health benefits may say, we see them for five minutes and give a prescription and it's cheaper than a counseling session."

Clayman said psychotherapy works to take care of the whole patient, but results are hard to quantify.

"The truth to it is, some mental health treatment can't be quantified or outcomes cannot be quantified like prescribing an antibiotic," he said. "Talk therapy seems to be so hard to get your arms around. I do know for instance that people do best with mental health with medicine, but some can be successfully treated without medicine and they do really."

Freedman said, though, the Affordable Care Act may not completely dismiss talk therapy as a solution.

"They are going to have to point to reasonable clinical standards," he said. "They won't be able to dismiss therapy out of hand. They're not allowed to discriminate based on health condition. If plans refuse to offer certain treatment protocols, they have to offer reasonable clinical judgment for making that decision. It's conceivable that you may see some changes in plans wanting to cover other therapies but they will have to have science to back it up."