Ohioans urged to get mental health help during pandemic. But what if insurance doesn’t cover it?

Dr. Brian Merrill, psychiatrist and Wright State director of residency training and community psychiatry. Merrill is  OneFifteen assistant medical director.
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Dr. Brian Merrill, psychiatrist and Wright State director of residency training and community psychiatry. Merrill is OneFifteen assistant medical director.

Ohioans have been urged throughout the pandemic not to be afraid to seek mental health care, but getting over the stigma is just one barrier.

Many struggle to understand their insurance and to find an available and affordable provider.

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A 2006 state law and 2008 federal law together generally require that health insurers cover mental health benefits as thoroughly as physical health benefits — a requirement often called parity.

But studies have indicated parity laws have fallen short on improving mental health care access. The complex issue can be difficult to enforce and to raise awareness about. That can translate to some people finding it hard to get and pay for care.

“Delays in treatment can be catastrophic in some situations, or very impairing,” said Dr. Brian Merrill, Wright State University residency training director for psychiatry.

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Trying to find care

During the pandemic, demand for mental health care surged, filling open appointments in an industry already in short supply of professionals.

Dayton resident Jocelyn Rhynard, who has private employer-based insurance, said she has tried to find an available therapist in her network since last summer, in a cycle of getting frustrated with dead ends, pausing, and then re-trying the search every couple of months.

“I would spend hours for a couple days just calling and writing emails and trying to reach out, finding phone numbers that don’t work, finding people that sound like they would be a good fit, but they’re not taking new clients,” Rhynard said.

Then last week she finally found someone who seemed like a good fit for the care she needs and was accepting patients, but is not in-network. Rhynard said she is going to see if her insurance will still partially cover the cost.

“Having a good relationship with a therapist is dependent upon regular communication, and if my insurance doesn’t cover at least part of this, I don’t know how often I can talk with her,” she said.

Rhynard, who’s also a Dayton Public Schools Board of Education member but was speaking only from her own perspective, said she’s grateful more people are talking about getting mental health care as a normal part of taking care of themselves. But then, the challenge of actually finding care was another layer of stress in the pandemic.

“I didn’t realize until COVID hit that there were a lot of issues that I needed help getting addressed,” Rhynard said.

Outreach

The Ohio Department of Insurance has a consumer help line at 1-800-686-1526 to help people understand their mental health benefits, or file insurance complaints and appeals.

In 2020, out of 2,068 accident and health insurance complaints sent to the department, 19 were related to coverage for mental health and substance use disorder services. Out of those 19 complaints, three were reversed in the consumer’s favor.

One challenge with reporting complaints of suspected problems is that many different types of health insurance are regulated by many different agencies. Not everyone knows what type of insurance they have.

Ten of the complaints filed with the state agency about mental health coverage were referred out because they were outside of the department’s jurisdiction. The Ohio Department of Insurance has jurisdiction over about 14% of the health insurance plans in the state, such as if a person has a fully insured insurance plan through an employer.

ExplorePREVIOUS COVERAGE: New rule demands parity for mental health coverage

If a person has Medicaid or their company is self-insured, those are other hotlines.

Not every insurance plan is covered by parity laws.

Most plans people buy directly (not provided through an employer) are required to provide mental health and substance abuse disorder benefits and follow parity. Many plans provided through an employer might have mental health and substance use disorder coverage, but not all are required, according to Sara Donlon, Ohio Department of Insurance communications director.

Medicare does not have to follow parity laws, except for cost-sharing for outpatient mental health services.

“It’s extremely complicated. I think there are a lot of people in the right place, trying to make it better, but the complexity is so challenging,” said Montgomery County Juvenile Court Judge Anthony Capizzi, who oversaw the creation of the Montgomery County Juvenile Mental Health Court and Family Treatment Court.

Young people involved with the court system can get help navigating mental health care, Capizzi said. But many working poor and middle income families struggle to understand the system and pay for care.

“We shouldn’t have to wait for the crisis intervention situation,” he said.

Enforcement

Gov. Mike DeWine’s administration has pushed to improve mental health access. State agencies spent $500,000 in two media campaigns in 2020 that got more than 37 million impressions. They went out to outreach events. They manned a hotline. They held webinars. They published a Mental Health Toolkit online. Ohio Department of Insurance and the Ohio Department of Mental Health and Addiction Services track progress with an annual parity report.

“It’s important that Ohioans reach out and tell us about their experiences with mental health insurance coverage,” Donlon said. “We are always willing to help consumers troubleshoot these types of insurance issues.”

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Many states have found parity enforcement and awareness challenging, noted a federal report from July 2021 focused specifically on Medicaid. The report said parity requirements have not improved access to behavioral health for people with Medicaid or Children’s Health Insurance Program (CHIP) coverage, and that parity analysis takes substantial amount of time and expertise.

An April 2021 report by the GAO looking more broadly at parity also raised questions about how effective the federal law has been.

Why aren’t more providers in network?

People go out of network more often for mental health care than for physical health care.

Insurers are supposed to maintain similar levels of in-network providers for mental health and physical health care.

A shortage of providers is one barrier, said Merrill with Wright State.

Studies also have shown insurers often reimburse behavioral health providers at lower rates. That can drive fewer providers to deal with insurance.

“They’ll pay less or have restrictions, and it’s sometimes just really inconvenient, the amount of administrative burden associated with private insurance,” said Merrill, who is also OneFifteen assistant medical director.

Kelly O’Reilly, CEO of the Ohio Association of Health Plans, said health plans actively seek to contract with behavioral health providers to provide access, as well as to meet network adequacy requirements. She said they talk regularly with providers about ways to improve workforce challenges.

“The better the behavioral health workforce situation is, the more access to care for behavioral health there will be — and we all have an interest in supporting that,” O’Reilly said.


What are health insurers required to cover?

Generally, two laws work together to create the framework for mental health coverage in Ohio.

A 2006 Ohio law requires coverage for diagnosis and treatment of specific biologically based mental illness, including major depressive disorder, bipolar disorder and schizoaffective disorder, to name a few.

The federal parity law, the Mental Health Parity and Addiction Equity Act, passed in 2008 and was put into practice in 2013. The law generally requires health insurance plans to cover mental health and substance use disorder benefits similar to how they cover medical and surgical care.

The National Alliance on Mental Illness said some signs that your health plan might be violating parity requirements include:

  • Higher costs or fewer visits for mental health services than for other kinds of health care.
  • Having to call and get permission to get mental health care covered, but not for other types of health care.
  • Getting denied mental health services because they were not considered “medically necessary,” but the plan does not answer a request for the medical necessity criteria they use.
  • Inability to find any in-network mental health providers that are taking new patients, but can for other health care.
  • The plan will not cover residential mental health or substance use treatment or intensive outpatient care, but they do for other health conditions.

Source: NAMI; Ohio Department of Insurance

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