Wednesday, October 15, 2008

Reducing Discrimination in Health Insurance

Come new health insurance plan implementation in January 2010—yes, that’s 2010—arbitrary and discriminatory health insurance treatment of many mental disorders will cease. CHADD has been very involved, with the entire national mental health community, in getting the Congress of the United States to pass mental health parity. Mental health parity is a legal means prohibiting insurance discrimination based on a mental or substance abuse disorder. Influencing public policy to assist people with AD/HD and related disorders is a major purpose of CHADD.

In 1996, Congress passed a “partial” mental health parity law that prohibited annual and lifetime expenditure limits on health insurance coverage of mental health treatment. The 2008 law prohibits differences between coverage for mental health and physical health treatment with regard to copayments, deductibles, and number of visits. While the new law became effective in October 2009, most health plans take effect in January. Thus, you will see this reflected in health plans in January 2010.

The law sends a positive message reducing the stigma against mental disorders. The enforceable law establishes federal public policy to eliminate overt discrimination against and to increase treatment for mental disorders. But there are gaps in the law.

The New York Times cited federal officials who said the law would improve coverage for 113 million people, including 82 million in employer-sponsored plans that are not subject to state regulation. Employers who employ fifty or fewer people are not covered by the law. The law does nothing for those without health insurance. The law allows a company to apply for a cost exemption if the company can demonstrate a greater than two-percent increase in actual costs the first year.

Not every condition listed in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, is covered. Health plans have discretion on which conditions to cover. While advocates of this provision typically cite such things as caffeine intoxication and sleep disorders resulting from jet lag, at CHADD we know of health plans that do not cover adult AD/HD. Until the published science is as sound for adult AD/HD as it is for childhood AD/HD, there will be plans that will not cover adults. CHADD continues to advocate a better science base for the diagnosis and treatment of adult AD/HD.

The law allows the “management” of health benefits and the cost estimates underlying the law assume “managed care.” We will likely see more tightly managed mental health benefits, meaning claims by the health plan’s management agent that treatment is not “medically necessary” or “clinically appropriate.” But under the new law, insurers must disclose their criteria for determining medical necessity, as well as the reason for denying any particular claim for mental health services.

So, we have made a significant step forward in helping people with AD/HD, particularly those with more complex cases of AD/HD, and those with co-occurring disorders. But we will continue to need public policy advocacy to deal with barriers and obstacles. We will continue to need a more solid science base. CHADD’s financial resources are currently under stress, given the economy. We encourage you to help CHADD in our advocacy efforts.

Copies of the new law, HR 1424 (which will be published as P.L. 110-343), are available here; see pages 117-129.



Unknown said...

It's true that sometimes insurance can be confusing. It's good to have as much information as you can before making a decision.

Anonymous said...

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Unknown said...

My very healthy 19 year old was turned down for health insurance coverage last week. The reason stated was her Abilify use and her ADD.