A "Win" For Mental Health Parity

Good news came out of California this week, signaling that progress is being made in holding insurers accountable to state mental health parity laws. A federal appeals court issued a decision that was structured around the state's mental health parity law, finding that even when a private insurance plan excludes mental health treatment, it still must be covered under state law. Recall that in 2008, the federal government passed the Wellstone and Domenici Mental Health Parity Act, which requires individual plans and companies with more than 50 employees to provide the same coverage for physical ailments and mental health services. States have adopted their own mental health parity statutes that demand increased coverage, in addition to existing insurance mandates; the Affordable Care Act also includes mental health services on its list of essential health benefits, which state-licensed health insuring organizations are required to cover in their health insurance plans. 

In the case that went to California's court of appeals, a woman's coverage at a residential treatment program was denied, and insurer Blue Shield asserted that residential treatment wasn't "listed" in the Mental Health Parity Act for the state. The Ninth Circuit ruled the "law requires insurers to pay for all medically necessary treatment for severe mental illness." Kenny Goldberg of KPBS public broadcasting in San Diego reports that the deputy commissioner with the California Department of Insurance has seen other insurers try to dodge paying for mental health treatments. He quotes her as saying, "Despite the passage of the mental health parity law more than a decade ago, insurers have just been reluctant and resistant to complying." However, it often falls to the consumer to "know the rules" in order to challenge the insurer! In California, insurers MUST cover treatments for severe mental illness, even if the policy excludes it. In Wisconsin, Governor Doyle signed "mental health parity" legislation into law in April 2010.  Wisconsin’s new law applies to all businesses in the state with at least 10 employees.

A Closer Look at Mental Health for Children

Guaranteed Coverage Through EPSDT (HealthCheck)

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a comprehensive, preventive well-child screening program for Medicaid-eligible children (under age 21). Congress added the EPSDT component to Medicaid in 1967 in response to documented, widespread, preventable mental and physical illnesses among low-income children and to promote the early detection and treatment of health conditions that could lead to chronic illness or disabilities. Called "HealthCheck" in Wisconsin, the purpose of EPSDT is to assure that all Medicaid-enrolled children receive periodic, comprehensive health screening exams resulting in the identification and provision of medically necessary health care services.
Why bother with HealthCheck? Here are just a few of the many reasons:

• Children and families struggle accessing dental care
• Children hit routine limits to mental health care
• EPSDT offers broad coverage
• EPSDT is less expensive than private coverage
• Per Capita, the cost of insuring a low-income child under Medicaid saves money
• Benchmark Plan affects coverage for thousands of Wisconsin children under age 21
• All Benchmark-enrolled children are eligible for Standard Plan benefits
• Coverage limits of Benchmark Plan DO NOT APPLY
• Children get the services they NEED and are entitled to under federal law

Yet, problems using HealthCheck persist. Providers skip "ages and stages" questionnaire due to time constraints during well child visits. Families are having trouble navigating mental health treatment, especially eating disorders/OCD and residential treatment. And, the case out of California reminds us that no matter the rules on the books, hoops and hurdles, and sometimes legal action is required to ensure the screening and treatment guaranteed in federal and state law! Stay tuned to future HealthWatch newsletters and publications on EPSDT and HealthCheck in Wisconsin, as we describe children's rights, the rules and the requirements to be assured all medically necessary services.