Mental Health Parity Still a Distant Wish for Most

Mental health parity remains a constant battle for young and middle aged populations of Americans seeking mental health services for drug and alcohol abuse, eating disorders, rape counseling, and posttraumatic stress disorders (PTSD). The challenges that such individuals face often go against insurance “standards” when it comes to provision of care. Unfortunately, when it comes to mental health and issues, the watchwords of most insurance companies still utilize the acute care standard – “if not suicidal, have to discharge”.

The Paul Wellstone Mental Health and Parity Act signed into law in 2008. The act sought to ensure that insurance companies treated mental health issues and substance abuse disorders on the same level as physical illnesses when a person’s insurance policy offers coverage for both. Since then the Affordable Care Act the mental health parity was extended to provide equal benefits with medical coverage, even for individual health insurance coverage.

Unfortunately, actual changes are not taking hold. Mental and substance abuse problems are still considered only on an acute care basis. Regrettably, such issues are often chronic in nature and necessitate long term management.

An alarming number of individuals between the ages of 20 and 30 are finding it increasingly difficult to obtain care coverage for mental health issues and related behaviors. County health services have begun to develop “transition programs” but in some areas, a four plus month wait or longer is typical. Individuals, including those dealing with PTSD, substance abuse, and eating disorders, are either being denied access to such care facilities or are being discharged from their treatment programs early. When an individual’s treatment courses are cut short, they often return home with ineffective coping skills that lead to relapses and in some cases, death.

60 Minutes recently ran a story related to denial of mental health coverage by insurance companies despite doctor’s prescribed orders for treatments of mental health and addictive behavioral issues. In fact, the exposé noted that many insurance adjusters “aggressively” review not only chronic cases, but long-term mental health care needs. Most health insurance companies often deny coverage for full treatment care plans, cutting off benefits at the halfway point.

In an attempt to enhance mental health treatment opportunities, the Affordable Care Act has shown significant improvements for those seeking care in physician and therapist office settings. Unlimited visits are a definite improvement for those with manageable mental health problems. Unfortunately, for those needing intensive outpatient or inpatient services, the quality of care and the number of in-network providers are limited.

Most reputable mental health treatment centers are out-of-network, placing a significant financial burden on patients and their families. Many of these patients are young adults still in college or high school, which creates a volatile situation within the family dynamic. Young adults often blame parents for their substance abuse; divorce, neglect, emotional distance are just a few reasons. Yet most parents paying for their children’s treatment don’t share this blame.

In today’s healthcare economy, insurance companies are the ones who determine duration of treatment, which makes it extremely difficult not only for patients to receive the care they need, but for patients and family members to struggle through the requirements and demands of filing claims, billing and reimbursement for such services.

Real solutions are only possible with genuine consideration from insurance companies. The Alliance of Claim Assistance Professionals (ACAP) strongly urges our readers to file appeals on all levels, as ACAP experience tells us that meaningful review takes place at the Departments of Insurance levels. Significant change will only come by filing mental health denial appeals to state insurance departments.

Nursing Home Medicare Coverage – Skilled vs. Custodial

Obtaining reimbursement from Medicare or third party payor insurance companies has become increasingly complex, especially in today’s healthcare environment following changes in how health care providers and facilities bill for services. Hospitals now discharge patients at a faster rate, often referring them to nursing homes or long-term care and rehabilitation facilities for aftercare services.

Costs for skilled nursing facilities or nursing homes are covered only when skilled nursing rehabilitation or care occurs within 30 days of a three-day long or longer hospitalization and is deemed medically necessary. Medicare Part A does not cover skilled nursing facility care if the patient does not require such services and only requires custodial care.

What’s the difference between skilled rehabilitation and custodial care? Medicare does not cover or reimburse for custodial care when it’s the only kind of care required by a patient or resident. Custodial care is defined as care offered to a patient or resident that does not involve or require skilled nursing services. Help with bathing, dressing, toileting, and other activities of daily living that don’t require specific and licensed medical skills are classified as custodial care.

Skilled nursing care can involve medical treatments and procedures (catheter care, Nebulizer treatments, breathing apparatus, etc.), medication oversight, wound care, physical therapy and other services where a patient or resident requires continued medical care on an inpatient basis. Skilled rehabilitation is deemed medically necessary to provide maintenance or improvement of health to a patient or resident. Skilled rehabilitation services must be supervised or delivered by licensed professional or technical medical personnel in order to achieve a specific medical outcome.

When factoring in reimbursement, be aware that Medicare Part A generally kicks in during the first 20 days, with 100% of the amounts approved. The longer you stay in a skilled nursing facility, the less Medicare eventually pays out. For example, the 2015 figures for reimbursement claims specify that between days 21 and 100, a patient’s coinsurance will pay $157.50 per day for each benefit period. After day 100, the patient is responsible for all costs.