Karen Bailey’s 20-year-old daughter has been suffering from depression and anxiety for years. Since 2017, she has participated in three intensive group therapy programs, each time a family insurance company has shortened her coverage, says Bailey.
“At some point, they will send us a stylized letter like this: we decided she was all getting better, it’s no longer needed, so we’ll cover it anymore I won’t do it, “said Bailey, 59, who lives in Los Angeles. “And believe me, she wasn’t all good. In some cases she got worse.”
Insurers often use their own black-box criteria, which are unknown to registrants and inconsistent with standard treatments, when making coverage decisions regarding mental health and addiction treatment, the government said. Julie Snyder, Director of Issues, said. Steinberg Institute, Sacramento-based mental health policy and advocacy group.
California law that came into force on January 1. SB-855, State-regulated commercial health insurance should make it much harder to do so.It requires them to use the nationally recognized clinical standards established by Non-profit organization of clinical professionals Decide what mental health and addiction treatment to cover and how long to cover it.
This is because, for example, insurance companies limit clients to only one week of home addiction treatment if 30 days is the clinical standard, or the most direct of anorexia rather than the underlying psychological factor. It means making it more difficult to treat only physical symptoms. , Says Snyder.
“This is a very strong law and can really be a game changer,” said executive director and founder Karen Fessel. Mental Health and Autism Insurance Project, Supported the legislation.
There has never been a better time to enhance mental health coverage. The pandemic anniversary is approaching. Leading to an increase Depression, anxiety, substance use, suicidal ideation.
Importantly, the new law, which updates and replaces California’s previous mental health equality law, dramatically increases the number of conditions that insurers must cover.
The state law that was in force until this year is Nine “severe” mental illnesses, Schizophrenia, bipolar disorder, major depressive disorder, and “serious emotional disorders” in children. SB-855 is conditions Range from mild to severe.
Federal law has already demanded broader coverage, but in vague terms, health plans are often circumvented by their restrictive definition of what is medically necessary, patient advocates say.
By expanding the range of conditions that health insurance must cover and keeping them to stricter standards regarding the type and amount of care they have to pay, the new law opens up a “loophole that allows you to drive a Mack truck.” Close. State Senator Scott Wiener (D-San Francisco), the person who created the legislation.
For years, many health plans have refused to cover mental health treatments until the patient is in jeopardy, Wiener says. The new law “ensures that people can be taken care of quickly while they still have homes, families and jobs.”
Another important aspect of the law is to require health insurance to cover off-network providers at in-network costs if registrants cannot find timely treatment at a reasonable distance. 15 miles or 30 minutes — From their home.
“That’s what we always encounter,” says Bailey. She says the family has spent years spending $ 100,000 on off-network mental health providers for their two children.
Opponents of the new law, including the California Health Planning Association and the California Chamber of Commerce, have significantly increased health care costs, exposed insurers to ongoing proceedings, and through strict definitions of health care providers, health care providers. Claims to interfere with ability. To decide what is best for the patient.
Proponents say the healthcare needs guidelines set by the Association of Professionals give healthcare providers a wide range of discretion in determining the best treatment for each patient.Ann analysis In the first year of law enforcement, implemented for state legislators by the California Health Benefits Review Program, premiums and registrant cost sharing were estimated to increase by only 0.002%.
The new law does not help everyone: it only applies to state-regulated commercial health insurance that covers some 13 million Californians — About one-third of the state’s population. It does not include Medi-Cal, which insures one-third of state residents, and federal-regulated commercial plans. Almost 6 million..
Because Small share Mental health advocates struggle with their health plans over refusal of care for many patients, but hard-working enforcement by the managed health care department Majority It will discourage insurance companies from denying the care that commercially insured Californians need in the first place.
Rachel Aresola, a spokesman for the agency who opposed last year’s bill, said it was fully intended to ensure compliance and began doing so.
But if your health plan still denies the care you believe you need, fight it, says patient advocates and health care lawyers.
“We need to be vigilant, we need to defend ourselves, we need to appeal the refusal, and we need to do it in writing,” says Kali Schwartz, a Los Angeles lawyer on behalf of the patient.
When appealing a decision over the phone, Schwartz says, take detailed notes, write down the date and time of the conversation, and get the name of the person who spoke to you. Create a file of all communications and other information relevant to your case, she says.
And be persistent. “I think insurance companies rely on individuals who give up fighting,” Schwartz says.
If you need help, please contact the Health Consumer Alliance (1-888-804-3536 or www.healthconsumer.org), We provide free advice and legal services.
If your mental health provider requests a particular type of treatment in 2020 and it is rejected by your health plan, resubmit this year to your provider as changes in legal circumstances may be in your favor. Ask them to do so, says Snyder of the Steinberg Institute.
Most commercial health insurance can be challenged within 180 days of receiving the refusal. You need to appeal to the insurance company first. If you do not respond after 30 days, or if you support the decision, you can submit it to the regulatory body for the policy.
In most cases it will be the managed healthcare department (www.dmhc.ca.gov Or 1-888-466-2219). There is a help center where you can file a complaint online. If your regulator is the California Insurance Department, you can call helpline 1-800-927-4357 for advice and file a complaint on its website (www.insurance.ca.gov).
Most Californians with commercial health insurance refuse treatment because the insurance company decides it is unnecessary or experimental, or the insurance company does not refund emergency medical care. If you are entitled to a review by an independent medical professional.
Reviews that can be requested through state regulators are well worth the effort. Approximately 60% of independent medical reviews submitted through the managed healthcare department result in patients receiving the first rejected treatment, Arrezola says.
Be sure to open the archive on the managed care website (https://wpso.dmhc.ca.gov/imr/), You can search past decisions to find cases similar to yours. They can help you build your discussion.
Ultimately, the usefulness of the new law depends on the will of the regulator that enforces it and the will of the consumers who use it.
“If you’re lucky, that means you don’t have to take out a $ 50,000 mortgage at home to pay for opioid treatment for your children,” says Snyder. “Unfortunately, it’s too common.”
This article was reprinted from khn.org With permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorial independent news service, is a program of the Kaiser Family Foundation, a nonpartisan medical policy research organization unrelated to Kaiser Permanente.
New California law facilitates mental health and substance abuse care
Source link New California law facilitates mental health and substance abuse care