Therapy in L.A.

 

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October 1999
THE REALITY OF MENTAL HEALTH BENEFITS
By Joyce Parker, Ph.D.

The Monday September 27, 1999 Health News section in the Los Angeles Times ran an excellent article on choosing health insurance. Times staff writer, Robert Rosenblatt, cautioned the public not to overlook mental health benefits in their decision. He pointed out that mental health has been hardest hit in the overall cuts in health benefits. For example, the average hospital stay for a physical illness has been reduced from 6.8 to 5.2 days, a reduction of 23% from 1990 to 1993. However, during the same period, the average hospital stay for a mental illness was slashed 47%, from 20.7 days to 10.9 days.

As a psychotherapist in private practice who deals every day with managed mental health care and other mental health insurance, I can further elaborate on the sad state of mental health benefits and the hidden opportunities that the insurance companies use to limit access and benefits. The article recommends that individuals select a plan that has a good selection of psychiatrists, psychologists, social workers and other counselors. Finding the right therapist is something like finding the right mate. Without adequate variety, a match may not be found. I am seeing several people in my practice who have mental health coverage through their HMO, but aren't using it because there were few alternatives to their assigned therapist. Others had to wait several weeks for an appointment and then were told that they would be seen only every two to three weeks for therapy. When employers change insurance coverage, employees may have to discontinue treatment if their therapist is not on the new list of providers. This disruption in the continuity of care is particularly difficult for mental health because the relationship and the understanding of the patient's history are central to the healing process.

Consumers also need to be aware that they will bear a greater share of the financial burden for mental health care. The maximum hospital stay is often limited to 30 days per year. Visits to a therapist are usually capped at around 20 to 30 per year. The co pay per visit can be as high as 50 to 60% of the fee. Some companies cap their pay out at $25.00 per visit leaving the individual with a co pay that can be as high as $75 to $100 per visit. Managed care has also added a stipulation that the sessions must be authorized and meet the criteria for medical necessity. The problem with this regulation is that there is no standard definition of this term. Managed care companies tend to interpret medical necessity based on the contract they have signed with the employer. That agreement is not available to the employees. So it is not until they attempt to use their benefit, that this loophole is recognized. For example, many of my patients have 45 sessions per year from one particular managed mental health company. However, if they work for one employer, they may be able to use 30 of those sessions. If they work for another employer, they will probably be able to use only 15. This brings me to another point. Managed care companies use the medical necessity clause in their contracts to deny individuals the full use of their benefits. Although I write treatment reports and advocate for my patients, the case managers at these companies begin to put pressure on me to terminate prior to the allowable limit of sessions. At least 90% of my patients' benefits under managed care are cut off before they are able to use their maximum session allowance for the year. The case managers tell me to send these people to self help groups, church groups or to suggest medication. The language of "medical necessity" is a slippery slope for the consumer.

Rosenblatt suggests "…the final message to consumers is: Be assertive, not ashamed. Rather than demand better coverage at work, too many people suffer in silence. Don't be embarrassed to use benefits promised under the health plan." I will add another exhortation: If your actual mental health benefits do not agree with those promised in your benefits book, complain to your employer and your insurance company.

The author of this article, and founder of the Therapyinla.com website, Joyce Parker, passed away in 2011. To honor her we are keeping her articles posted at this website.


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