Trump Presidency: What this Means for Your Mental Health Care

 

I’m going to touch upon a few things with some educated guessing since at this point we have no information on any strategy for changing the healthcare system, including the Affordable Healthcare Act (aka. Obamacare).

Medications

Big Pharma may be big winners in this election. There is a good chance regulation will decrease which means drugs will be pushed through the regulatory process. There is also a very good chance your medications will get more expensive Obamacare will be directly targeted for dismantling. At this point, the federal government has some impact on what drug makers charge (at least for Medicare, Tricare and Medicaid clients). There is a very real fear that whenever there is a conflict between industry and clients/customers, the Trump administration may very well choose big business.

Affordable Health Care Act – Obamacare

This was one of Trump’s big targets and will likely be a focal point as the Trump administration sharpens its agenda in 2017. One big problem with Trump’s over simplistic promise to ‘get rid of Obamacare’ is that it took years and years to recalibrate and organize healthcare at the federal, state and corporate levels. Billions of dollars went into this law. Changing the law will take years and years and more billions. Insurance rates have gone up for many people and that hurts. But, the dismantling of Obamacare will likely have a dramatic and catastrophic effect on providers, clients and hospitals. The prediction at this point is that while the current system is experiencing growing pains, the replacement will likely compromise the little leverage we have over insurance companies meaning they will go back to charging whatever they want and having pre existing conditions the hallmark of how they keep people from needed care.

Mental Health Parity and Addiction Equity Act (MHPAEA)

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical benefits. With the Trump administration taking the reigns in a few months, there is the possibility the act could be dismantled in favor of insurance companies, most of which have fought, lied and deceived policyholders from the very beginning of the law in 2009. What this means for you: Insurers may no longer be required to pay for comparable level of mental health and substance abuse treatment as you have within your medical policy.

I will continue to monitor Trump policy changes and post again soon. Till then, take a deep breath, stock up on canned goods and sweep out your bomb shelter. We’re likely in for a wild ride.

Insider’s Guide: Getting Insurance to Pay for Residential Treatment

imagesThis is our second installment on how to get insurance to pay for residential treatment and therapeutic programs. Below is some great information to help you beat the insurance companies at their own game. Insurance companies count on your ignorance, laziness and distractibility to avoid paying for services they are legally obligated to cover. 

With the Affordable Healthcare Act and the Mental Health Parity Act in full swing it’s time to learn how to get the most out of the insurance you pay for. We’ve included some tricks, strategies and how-to’s to help you out. Though we’re focusing on Residential Treatment for our discussion here, this info is applicable to therapeutic programs like wilderness programs, therapeutic boarding schools and intensive outpatient programs.

Ok, let’s get started with some basics… 

What If I Need Additional Help?

First, read through everything below. These strategies are time consuming and require steady attention but they are not impossible. If you still don’t feel confident in holding your insurer accountable, contact us for a free consult and we’ll help you figure out how to move forward. 

What is the Insurance Company’s Criteria for Residential Treatment?

…Or more importantly, how does an insurer define residential treatment? Each insurer has their own definition but most have virtually identical criteria. For our purposes, residential treatment is defined as specialized mental, behavioral health or substance abuse treatment that occurs in a residential (overnight) treatment center where the provider is responsible for clinical service, safety, shelter, and food.

Licensure differs by state, but these facilities are typically designated either as residential, subacute, or intermediate care facilities and may occur in care systems that provide multiple levels of care. Residential treatment is 24 hours per day and often requires a minimum of one physician (or psychiatrist) visit per week in a facility based setting. 

What Specific Criteria Do They Look For?

Now, let’s drill down a bit more and look at some of the more common criteria requirements insurance companies are looking for when determining whether to pay for residential treatment to a struggling teen or young adult. 

  • Was there a sincere attempt to first use evidence-based outpatient therapy in the home community by a licensed professional before residential treatment was requested and outpatient therapy did not work? Basically, they want evidence that you tried outpatient therapy with weekly sessions (or more often) and because it was not effective, a more intensive level of care like residential treatment was justified.
  • Prior to admission, did you contact your health plan for list of in-network residential treatment options? More on this later – what to do if you can not find a good option.
  • Is there uncontrollable risk-taking to self or others or other dangerous behavior?
  • Has there been a documentable and rapid decrease in level of functioning in one or more life domains. Another way to describe it is a decline in functioning resulting in the ability to perform self-care. 
  • Is there a likelihood of no improvement in current environment (ie. home or college)
  • Is there a reasonable expectation that patient will improve in residential setting and be able to return to outpatient therapy for aftercare? 

How to Request this Higher Level of Care?

Now that you understand the criteria, let’s talk about how to actually request residential treatment. 

  • Write a letter strongly recommending admission to residential treatment 
  • Provide copies of assessments and testing performed by a licensed professional that indicate 1) a formal diagnosis and 2) specific recommendations that list residential treatment.
  • Explain how outpatient therapy has not been successful
  • Explain why current circumstances make it unlikely that patient will show improvement (ie. Improvement is not likely in home setting due to social stressors such as negative peers that sell drugs but remain in the environment)
  • Document unsafe, declining behaviors – show symptoms and behaviors that represent a decline from usual state and include either self-injurious or risk-taking behavior that cannot be managed outside of 24 hr care. Can your kid maintain abstinence outside of 24 hr care? 
  • Explain that the residential treatment program uses evidence-based clinical interventions.
  • Request the residential treatment program directly contact your insurer for pre-authorization. Pre-authorization is the insurance company’s way of giving formal permission to use a higher (and more expensive) level of care. Make sure to obtain the tracking number and verification of the call from the residential treatment program. If approved, obtain written authorization confirming admission approval.

After you send off your request, your insurer should should respond in 5 days. Don’t wait that long – call them every day to find out the status of your request. Yes, seriously – call every day. 

Accepted! Now Some Additional Insurance Mandates

The insurance company accepted your request (more below on what happens when they do not accept it) and a wave of relief comes over you planning for some quiet time once your kid is safely transitioned. But before you get too comfy, there are a few things you want to make sure the residential treatment program will do to ensure insurance covers as much as possible. It’s easier to ask these questions during the admissions process rather than at discharge. Here’s a list of what to look for or ask for:

  • A basic physical during admission (urine screening for drug facility)
  • Onsite nursing and 24hr access to med care
  • Multidisciplinary assessment (also called a Biopsychosocial Intake) performed within 72 hr of admission, including information obtained from patient’s previous providers (ie. therapist, primary care physician)
  • Individual therapy with a licensed therapist (ie. LPC, LCSW, LMFT) at least one time per week
  • Weekly meetings with doctor for medication management
  • Weekly family therapy
  • Discharge plan created one week after admission which acts as a set of exit criteria
  • Licensed in the state in which they are located. Some facilities are owned by huge companies in another state. Make sure they are credentialed and licensed.

Denied. Now on to The Appeal Process

Denials are just a way of life in the therapeutic treatment world but it’s certainly not the end. Here are some information on what to do when you experience a denial.

  • First Thing – Do not let the denial get you mad and do not attempt to use logic, common sense or science to understand why. Insurance is a business and their business model is take in money and pay for as little service as possible – period. 
  • If residential treatment is verbally denied, request written denial. They must deny in writing and often will send the residential treatment program as well as the insured person a copy. 
  • Do not just ignore the denial and send your kid off unless you are willing to pay out of pocket and work your tail off at discharge to get the insurer to pay for it.
  • How to appeal depends upon the reason for denial. The insurance company will likely list specific criteria either your kid or the residential treatment program did not meet.
  • If the insurer states that residential treatment is not a covered benefit but they offer  other mental/behavioral health benefits, they are required by law to pay. In Harlick v Blue Cross of California – On August 26, 2011 the court confirmed that California’s Mental Health Parity Act requires health plans to provide coverage of “all medically necessary treatment” for “severe mental illnesses” under “the same financial terms as those applied to physical illnesses,” and are obligated to pay for residential treatment for people with eating disorders even if the policy excludes residential treatment.

And It’s Still Denied – What Next?

If you submit an appeal with additional information and site the law but still are denied or hear nothing, you can request an independent review from your state’s regulatory body that oversees insurance compliance. It’s amazing how quickly insurance companies can ‘find missing paperwork’ or reverse a denial when regulators and attorney’s get involved. 

  • Send a certified-mail cover letter describing the dispute
  • Provide all relevant evaluations, assessments and testing you already sent to the insurer
  • Submit a doctor’s letter stating care is medically necessary
  • You can also hire an attorney that specializes in insurance issues like this. They are often worth their specialist price tag.

Plan B – If You Can Afford It

If residential is denied and you don’t want to push the insurer for whatever reason, you can pay out of pocket for room and board and try to get the clinical services covered. This approach is often what is equivalent to out-of-network coverage. The insurer is more likely to cover outpatient therapy, group therapy and medication management (virtually the same as if client was living at home and going to therapy).

You can also request that the residential treatment primary therapist get a single case agreement which forces the insurer to pay at in-network rate and you only owe the copay, as usual. 

What if Our Family Member is at Therapeutic Boarding School?

With the growth of therapeutic boarding schools, we’ve received a ton of questions about how insurance pays for the clinical aspects of these hybrid programs. Here are some tricks we’ve picked up over the years:

  • Think like the insurance company – they want to hear your son or daughter is being referred to as a patient and not a student.
  • Make sure to request a physical assessment is done at admissions. This promotes the perspective that he/she is a patient and not a student. Remember – we want the insurer to understand this is a therapeutic program, not as much an academic program.
  • We also want to ensure the program is keeping daily records such as treatment plan updates, nursing and medical notes and service notes – health plans will want copies. We want to be documenting progress as well as setbacks. 

When we conduct placement services, we always request the therapeutic program develop a treatment plan with some specific exit criteria. The first day of treatment is the first day of discharge planning. Some plans will want exit criteria so err on the side of having the program provide it early on. It’s also a good clinical practice to give the providers a clear target. 

In Which State Should Insurance Regulators Be Notified if Insurance Refuses to Cooperate?

The state in which treatment is being provided is where insurance regulators should be contacted if your insurance company refuses to play nicely. The state in which you live may be where your insurance is attached, but legal oversight for provision of service and insurance regulation is in the treatment state. 

Can Insurance Pay for Services Retroactively?

Theoretically, yes. Practically, it’s pretty difficult and will require regular attention and contact with the insurer. They will likely ‘lose’ applications, claim forms and anything else you send. If you get insurance to agree to pay for residential treatment or other therapeutic services after treatment has started, you can request for retroactive coverage. It’s best to write a letter (and send it certified mail and keep a copy for your records) stating why you didn’t understand or it was not stated clearly in a policy that treatment was covered. 

Will Insurance Cover Partial Hospitalization Programs (PHP)?

Partial Hospitalization Programs or PHPs is typically a level of care designed for individuals who need structured mental health, behavioral health or substance abuse programming but do not need 24-hour supervision (ie. inpatient or hosplitalization). Many hospitals and residential treatment programs offer partial hospitalization or day treatment services. Good PHPs are designed to provide support, education, medical monitoring and accountability during the hours of the day often identified as most troublesome for patients. Patients participate in therapeutic groups, structured activities and discharge planning similar to those offered in the inpatient and residential programs. Many patients who have been in an inpatient or residential program can “step down” to this level of care because it continues to provide a high amount of structure and support. 

Insurance generally covers PHP at a per diem rate (daily rate) but will not cover overnight which the hospital or treatment program may charge extra for. Make sure to clearly understand how the treatment center charges for PHP before signing up. Also make sure insurance covers it and what portion it covers. 

So we covered several of the topics and tricks that can help you navigate the insurance company maze when it comes to paying for residential treatment. If you need additional help, contact us today – help@fonthillbehavioralhealth.com 

Getting Insurance to Pay for Residential Treatment

imagesSince paying for therapeutic treatments like residential treatment, intensive outpatient program and therapeutic boarding school with insurance is a big topic we’ve broken this into a few different posts. Today, we’re starting with the basics of the health care act that tightens up the requirements for insurers. Historically, insurance paid for outpatient services and residential treatment was only for more affluent families. But thanks to the mental health parity act, insurers are not more responsible than ever for paying for higher levels of care. 

What’s the Mental Health Parity Act?

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires many insurance plans that cover mental health or substance use disorders to pay for coverage for those services that are no more restrictive than the coverage for medical/surgical conditions. Basically, if they pay for medical stuff, they have to pay for mental health and substance abuse stuff – that’s the ‘parity’ part. 

What Does it Cover?

  • Copays, coinsurance, and out-of-pocket maximums
  • Limitations on services utilization, such as limits on the number of inpatient days or outpatient visits covered
  • Coverage for out-of-network providers
  • Criteria for medical necessity determinations

MHPAEA does not require insurance plans to offer coverage for mental illnesses or substance use disorders in general, or for any specific mental illness or substance use disorder. It also does not require plans to offer coverage for specific treatments or services for mental illness and substance use disorders. However, coverage that insurance plans do offer for mental and substance use disorders must be provided at parity (the same) with coverage for medical/surgical health conditions.

The original MHPAEA was enacted in October of 2008. The main purpose of MHPAEA was to fill the loopholes left by the previous Mental Health Parity Act was legislation signed into law on September 26, 1996 that requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical benefits offered by a group health plan.

What if My Plan is Not in Compliance?

Before escalating things and contacting state or federal officials, contact Fonthill to see how to ‘encourage’ the insurers to provide appropriate coverage (look for future blog posts on how to communicate and educate your insurers for coverage). If you still have concerns about your plan’s compliance with MHPAEA, you can contact the Feds or your State Department of Insurance. You can contact the Department of Labor at 1-866-444-3272 or http://www.dol.gov/ebsa/contactEBSA/consumerassistance.html. You can also contact the Department of HHS at 1-877-267-2323 ext 61565 or at phig@cms.hhs.gov or your State Department of Insurance at http://naic.org/.

Check back next time when we explore some tricks to getting insurance to pay for treatment – it’s what the insurance companies don’t want you to know. 

 

 

FREE Parent Support Group: Residential Treatment and Higher Levels of Care

If you are a parent who wants to learn more about residential treatment for your teen or young adult child, our Parent Support Group is for you. This group is specially designed for Parents of Teens and Young Adult Children either in residential treatment or in need of residential treatment. Whether you have an acting out teen obsessed with gaming or a daughter exhibiting what seems like an eating disorder, residential treatment may be an option. But how do you choose? How do you know the good ones from the bad? We will walk you through the basics of the therapeutic program world through a discussion format. 

Topics will range from residential and treatment options, how to creatively pay for programs and use insurance, myths vs reality of treatment, parenting advice and skill building, and finally, sharing and venting. This is also an open forum to address any other problems related to acting out teens/adults – you’re not alone. 

WHEN

Mondays 7:00pm Starting September 8

WHERE

Fonthill Counseling Conference Room – 141 Providence Rd Suite 160 Chapel Hill NC 27514

COST

Free

FACILITATOR

Licensed therapist with expertise in residential treatment, counseling and parenting education will lead didactic, interactive and experiential sessions.  

RSVP

Due to limited seating, preregistration is required. Please email us at help@fonthillcounseling for sign-up instructions. 

The Affordable Health Care Act (aka Obamacare): How it impacts Mental Health and Substance Abuse Service

The Affordable Health Care Act (aka Obamacare) has been ramping up over the last few months and goes into full-throttle (Health Insurance Marketplace enrollment starts October 1, 2013). Here are some of the important changes the healthcare law impacts. 

Expansion

The Affordable Care Act will expand mental health and substance use disorder benefits  and parity protections for 62 million Americans. Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy, prescription drugs. It also covers services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more. The healthcare act also includes a huge Medicaid/Medicare expansion to provide coverage to millions more Americans currently without insurance. Here are just a few other bullet points of the healthcare act going into effect soon: 

• National goals have been set to identify and reduce mental health care disparities in the U.S.

• More federally-qualified mental health care facilities will be made available and funded.

• There will be an increased focus on telemedicine, which will facilitate mental health services and collaborative efforts from a distance, through the use of telecommunication technologies.

• Additional funding will be allocated to mental health organizations, such as SAMHSA.

• State Health Homes will be made available for individuals recovering from substance abuse and mental health disorders.

• School-based mental health programs will be initiated for child mental health care.

• Grants will be allocated exclusively for training more mental health care professionals.

• No-cost and low-cost preventative screenings will include mental health services.

• Mental health benefits will be included in the Medicaid expansion.

Prevention

Most health plans must now cover preventative services like depression screening for adults and behavioral assessments for children at no cost. All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.

Pre-Existing Conditions

Starting in 2014, health insurance plans will not be able to deny clients customers coverage or charge extra for pre-existing health conditions including mental illness. 

Let’s Talk Access

Access through for those un- or under-insured is through Exchanges. Exchanges are set up through state websites designed to make it easy for people to find health coverage. Each state will have one. The District and 16 states, including Maryland, are running their own exchanges. The rest are either partnering with the federal government or, as in Virginia’s case, relying on the federal government to operate their exchanges. To find the correct site, go to www.healthcare.gov.

To learn more about how the Affordable Healthcare Act may impact services with Fonthill Counseling, please contact us with specific questions or concerns.