The Balanced Mind Foundation Live Event Transcript

Did you miss our chat with Jean Galovich? Read the transcript of this exciting and informative chat. The Balanced Mind Foundation will be hosting several more expert chats this Winter. Watch your email for more details.  

Biography
Jean is President and Founder of HealthMax, Inc., a healthcare intermediary services firm located in Downers Grove, Illinois. She has worked in and consulted with the healthcare industry for over twenty years. In her role with HealthMax, Jean draws on her knowledge of both health benefits and the structure and function of the healthcare industry to help clients with managing health benefit claims and resolving problems with claims processing, incorrect bills and access to providers.

Nanci 
Jean would you like to start off by giving us some background information about the mental health parity law?

Jean Galovich
Thanks Nanci, and hello everyone. I am glad to participate in this chat today, as I am a member of The Balanced Mind Foundation and have a seventh grader with a dual diagnosis of BP and ADHD. I also work with many families with one or more family members with serious mental illness.

As most of you can probably relate, this new law was necessary because most insurance plans have had more limited benefits for behavioral services than for other medical services--that is, limits on inpatient days or outpatient visits. The intent of this law is to eliminate those differences and promote parity in benefits. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was passed in October 2008 and was to take effect in October, 2009, but in the absence of federal regulations the law now becomes effective 1/1/10. The law applies to group plans with 51 or more employees, whether they are insured or self-funded. It also applies to Medicaid plans. In essence, the law mandates that if mental health benefits are provided they must be on a par with other medical benefits. That is, there can be no differing benefits on inpatient days or outpatient visits, or differences in coinsurance, copays or deductibles.

Jean Galovich
I'd be happy to take any specific questions anyone may have.

dmt
Are federal regulations planned or expected? And if so how will that affect the current Equity Act?

Jean Galovich
There has been formal communication between leaders in the House and Senate and HHS Secretary Kathleen Sebelius. The regulations are expected by January. They should address questions such as--can a plan have separate but equal deductibles for mental health services and other medical services.
The regulations are intended to clarify areas where there are options for compliance. Clearly the intent of the law is to make mental health services and benefits more widely accessible.

Nanci
Is there a significant chance that there could be two separate deductibles?

Jean Galovich
That's hard to say. I've seen varying figures in the amount of expected increases in overall plan costs, but they range anywhere from a half percent to five percent. It's difficult to predict how specific the regulations will be. I think having separate deductibles would be a barrier to more people seeking treatment and using their benefits.

Carrie
I'm curious what 'other medical benefits' are and if this would include or affect prescription drug benefits?

Jean Galovich
"Other medical benefits" are benefits provided for all other medical conditions besides mental illness. There is no provision in the law allowing for differences in prescription drug benefits for mental illness or medications for other medical conditions.
Carrie     
I ask about 'other medical benefits' because they are often covered differently (primary care doc vs. specialist, occupational therapy vs. chiropractic). Which would mental health benefits fall under?

Jean Galovich
Again, a great question. Mental health services would be considered specialist and not primary care (although some get their meds from a primary care doctor, and there are varying opinions on that). In terms of the outpatient visits, a plan can comply in two ways--they can either not limit those services, or they can put a limit on outpatient visits that would apply to any outpatient services (physical therapy, occupational therapy, therapy, physician, etc.), such as a limit of 60 total visits a year.

Melissa
When you say the law becomes effective 1/1/10 does that mean insurance policies that begin at that time must follow the parity law?

Jean Galovich
Thanks for your question. Most plans follow a calendar year, so most plans must comply with the law 1/1/10. If a plan has a new plan year starting July 1, then the date for their plan is 7/1/10. Collectively bargained plans do not have to comply until their next collective bargaining agreement effective date.

I have a client with two family members with mental illness who got his insurance coverage through a PEO. The PEO actually changed their plan year to 10/1 instead of 12/1 so they would not have to comply with the law for another year (That was before the effective date was delayed to 1/1/10).

Nanci
It's disheartening to see the ways that companies will go to great lengths to avoid what they are legally obligated to provide!

smallmom
Our current health care plan covers no mental health residential treatment. Is this likely to be addressed in the regulations?

Jean Galovich
Unfortunately the Act is silent on benefits that are specific to mental health, namely residential treatment and partial hospitalization. It is unclear if the regulations will address this.

dmt
Does the parity of the current Equity Act apply to how pre-authorizations or continued services are determined as well? For example, will insurance companies get to continue with their very restrictive level of care guidelines and their control for pre-authorization or continued services for coverage of acute inpatient and partial hospitalization? I ask because my son was just denied continuation of his partial hospitalization even though the facility doc said it was needed, the insurance company doctors said he did not and the insurance company. Denied it based on their own doctor’s review. By the way my son met their level of care guidelines as far as the facility doc was concerned and from what I read of their guidelines he did as well.

Jean Galovich
The industry articles and employer surveys I have read predict there will be increased usage of Employee Assistance Programs, preauthorizations, case management and carve outs with mental health services coordinated by a specific vendor. I would have as persuasive a case as possible, with documentation ready.

karenmmc
Does this law apply regardless of what state you reside in?

Jean Galovich
Various states have their own mental health parity laws. The Federal Act basically serves as a floor of benefits that is expected. If a state does not have its own law then the Federal law serves as the guide. If a state has a more restrictive Act, then the Federal law is what should be followed in most cases.

dmt
Do you know where (web address) we can to go to read the actual Equity Act?

Jean Galovich
http://www.govtrack.us/congress/bill.xpd?bill=h110-1424

Mom to four
Do you know how or whether parity has been addressed with any of the new health care reform legislation?

Jean Galovich
I don't believe there are any major provisions in the bills specific to mental health services, but as the debate continues we may see some change in that.

Melissa
My husband works for a large insurance company. We just received the new benefit package to go into effect 1/1/10. They cut the outpatient mental health coverage from 100% in network and 80/20% out of network to 50% for both outpatient and inpatient. Both of my daughters and I have bipolar and ADHD. With the new coverage we can't afford to continue to receive the services we've been getting. What do we do if we think the company isn't complying with the law?

Jean Galovich
The first place I would start is with the human resources department and tell the benefits manager that your understanding of the Act is inconsistent with the new plan benefits. If their response suggests they are not complying with the law, then I would contact your state’s Department of Insurance. This information can usually be found on the web site that lists all departments in a particular state's government and can be found by googling the state and the department you're seeking. In some states it might be referred to as professional regulation.

I would also check the back of your Summary Plan Description and see if the plan is subject to a federal law called ERISA. If so, there should be instructions on how to contact the U.S. Department of Labor. You said the employer is a large company but again there needs to be 51 employees for the plan to be subject to the Act.

Carrie
How do you anticipate this law will impact the number of mental health providers who accept insurance?

Jean Galovich
Good question. I think there should not be a change in the number they accept, but there may be increased scrutiny with a new plan or new provider on exactly what is covered. As we all know, there are some insurance companies that are better at expeditious approvals and claims payment than others.

lvsmith
Would this law mean that an employer would be unable to have different insurance coverage for mental conditions? For example we have a PPO for our medical but we were placed on an HMO for mental health benefits.

Jean Galovich
The law requires that the benefits be equivalent for mental health and other medical services, and there cannot be a difference in benefits provided. There also cannot be differences in how benefits are paid in network for mental health and medical, or out of network for mental health and medical.

elkabong
If an insurance company cannot technically 'deny" coverage for mental health visits, would they still be able to cap you out in individual plans at a set number of visits, scaling them to the number of outpatient medical visits. To put it another way, would they simply scale down the number of outpatient medical visits in order to say they've hit parity? The real question being how does the government have oversight of finagling to get around the regulations?

Jean Galovich
Again, the scenario you describe here does not sound like it would comply with the new law.

Nanci
So, an insurer couldn't decide to limit the number of medical office visits in a year as a backhanded way of reducing (or avoidingincreasing) mental health coverage?

Jean Galovich
It is possible that a plan can lower the benefits (e.g., number of visits) for all services to what they currently provide for mental health. It would be unwise for an employer to do that but it is possible. We will have to see what the regulations say.
dmt     
If the insurance company does not require pre-authorization for seeing a specialist, as in most PPOs, then does the Equity Act deny the insurance company from having pre-authorizations to see a doc or clinician for mental health?

Jean Galovich
That is my understanding, but we will have to see what clarification the regulations provide.  As clarification, the Act, as further defined by the regulations, are enforced by federal agencies, the main one being the Department of Labor.

Nancy
My insurance is Blue Cross Blue Shield of Kansas. We live in Colorado. There appears to be a difference in the criteria required for a therapist in Kansas. For example: LCSW vs. a Master degreed therapist with a counseling certification from Colorado. How do I get them to pay?

Jean Galovich
You could try to appeal any decisions with the insurance company. If the therapist you are seeing is as effective and less expensive, you might have a case. There are differences in licensing between the states that play a role here.

Nanci
I have a question that isn't specific to parity, but does affect many of our members because of the shortage of mental health resources. If we need to obtain services from an out of network provider, can you recommend any strategies for negotiating with the insurance company to get them to make an out of network exception?

Jean Galovich
If a case can be made that there is no in-network provider that can provide the needed services, then that is an avenue to pursue. You can try contacting the customer service area to find out their procedure for doing that. Some insurance companies have a consumer affairs area that reports directly to the president that can help also.

Nanci
We have just a few minutes left. Jean, are there any other pointers or information from your experience that would be helpful for our members to know about?

Jean Galovich
It is always best to negotiate up-front. While it's rare in mental health, any information on clinical outcomes for a specific provider would also be helpful if you can find it.

Nanci
Thank you so much for sharing your time and expertise with us, there are certainly a lot of unknowns, particularly with the delay in the regulations.

Jean Galovich
This is the time when a lot of companies are going to be modifying their benefits to comply with the law. I strongly urge you to contact the benefits manager for your plan so that they know the providers, benefits, and other things you may wish to share about your situation so that any changes they make will be favorable to you.

Nanci
Great point!

Jean Galovich
Thanks everyone, this has been a great discussion. I wish all your families the best in this period of new opportunities and transition

Nanci
Thank you again for joining us, Jean. You gave us a lot of great information. If people are interested in your consulting or advocacy services, how should they contact you?

Jean Galovich
They can contact me at Healthmaxinc@aol.com or by phone at (630) 910-6964.