- Financially Better for Clients. This maybe counterintuitive, but paying out of pocket for many healthcare services has been shown to actually be the same or less expensive. The average number of sessions I see clients in a year is 21. Here’s the math: 21 Sessions x $159/session = $3339. That’s a big chunk of money. But…whatever is not reimbursable to you by insurance is often tax deductible. Most healthcare expenses can also be paid directly with an HSA or FSA. Additionally, more and more families are choosing high deductible, lower fee plans. Pay $5000 deductible and then insurance kicks in. That’s after you’ve paid your $833/month.
- Less Complication. It takes longer to verify insurance, verify their plan covers my services and ensure they can be seen It is a fact that every document or form that needs to be sent to insurance is an opportunity for them to avoid financial responsibility. I’ve had dozens of situations where my office manager would send in a form and the insurance company would first claim they never got it. We’d resend it. Then they claimed it was not completed correctly. Resend after corrections. Then they would claim it was incomplete. This game can last up to a year (I’m still getting payments from insurance claims filed over a year ago).
- Clinical Decisions are Not Driven By Insurance. I’ve had way too many instances where an insurance company told me or the family that the client ‘no longer met criteria for services.’ What? How the heck would they know that? It’s based on the number of sessions they allot, the diagnosis I gave and how much money has been spent. At no time does insurance actually review my notes, talk to the client or family or inquire about the clinical status. No thanks – I don’t want insurance professionals making decisions for my clients. And just in case you were thinking it, I’m not a right-wing, libertarian nut job. This is actually my progressive, liberal side coming out advocating for my clients against huge companies whose sole business model is to take in as much money as possible and avoid contractual obligations.
- Flexibity. No insurance company has ever liked hearing that I’m on-call for clients and use texting, video chat, etc. to continue treatment and support between sessions. They also are not fans of me working with parents in a consulting manner. They don’t want to hear that I provide insider knowledge of treatment programs. None of this fits within their narrow definition of what a counselor should do. I do what is necessary to create stability and promote a healthier life.
- Protection. Until there are safeguards that protect clients from being blacklisted for a preexisting condition (ACA is currently under attack from the Trump administration for this) I’d prefer not be forced by insurance companies to diagnose a client. For me to get payment, I have to provide client’s name, diagnosis code, CPT code (what service I provided), my license information, and my NPI (national identifier for healthcare professionals). If I fail to provide any of that, the claim with be denied. In my opinion, there is no reason why a company needs evidence that a client has a diagnosible condition. I totally understand requiring all the other information but diagnosis is unnecessary. At times, a diagnosis is important for the client or family to hear and understand.
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).
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.
Since 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 firstname.lastname@example.org 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.
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.
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.
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.
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.