Insurance coverage for mental and physical illness remains unequal despite promises that Obamacare would help level the playing field, mental health advocates and researchers say.
A new study by the Johns Hopkins Bloomberg School of Public Health found that consumer information on a quarter of the Obamacare plans that researchers examined appeared to go against a federal "parity" law designed to stop discrimination in coverage for people with mental health or addiction problems.
This makes it nearly impossible for consumers to find the best plan to cover their mental health needs, the research suggests.
"It's critical to monitor whether these regulations are being implemented in a way that fulfills the promise of parity," says associate professor Colleen Barry, who led the study published in the current online issue of the journal Psychiatric Services. "Clearly, better monitoring is needed."
Barry and her colleagues examined benefit brochures offered during the first Affordable Care Act enrollment period in 2013-14 in two state-run exchanges, hoping to replicate a consumer's shopping experience. Although she won't name the states, Barry says one was large and the other small, and adds that the results can be extrapolated to plans offered in other states and on the federal exchange.
The study found two big problems: financial disparities such as different co-pays or deductibles for mental and physical health services; and more stringent requirements for "prior authorizations" from insurers before patients can get mental health services.
Such differences may steer people away from buying these plans, Barry says. She's concerned insurers have an incentive to do that because covering people who use mental health services tends to be more expensive.
The federal law first required parity for group health insurance policies in 2010, and Barry says as of Jan. 1, 2014, insurance plans on state exchanges were also required to offer plans with equivalent cost-sharing and prior authorizations for mental and physical health.
But Clare Krusing, spokeswoman for the industry trade group America's Health Insurance Plans, says the rules contained some important changes affecting plan design that were only required for insurance plan years that started on or after July 1, 2014. Krusing adds that it's unfair to say a plan doesn't offer mental health parity based only on what consumers see before buying the plans.
"It's nearly impossible to say a plan is not in compliance if you are just looking at the summary of benefits and coverage," Krusing says. "You have to look at the claims history to make sure it's at parity."
Differences in the levels of benefits in each state are designed with government oversight, and the amount of cost sharing is determined by tier of coverage on the exchange, points out Cigna insurance CEO David Cordani, who had not seen the study. Consumers who are unhappy with the level of coverage in their plan, for whatever reason, should "buy up" to a plan on a higher tier, he says.
In the eight states that it sells on the exchanges, Cigna's plans don't require prior authorization for outpatient mental health treatments, says spokesman Jon Sandberg. Cost sharing levels for behavioral health office visits are the same as the cost-sharing levels for other specialists too, he says.
Mental and physical health are inextricably linked, so benefits covering physical health may extend to some aspects of mental health, Cordani says. For example, the majority of antidepressants are prescribed by primary care doctors.
"Disconnecting the mind and the body, which is the way historically insurance wanted this, doesn't make any sense," says Cordani.
Mental health professionals say the medical system has discriminated against those with mental health or addiction problems for decades. Pre-Obamacare insurance plans often required higher co-insurance or deductibles for mental health care visits compared with physical health care visits, or capped the number of days patients could spend in a psychiatric hospital but not in an acute care hospital.
The ACA promised one of the largest expansions of mental health and substance abuse coverage in a generation, requiring that all new small group and individual market plans offer mental health services, and cover them on par with medical benefits. That means if there's a 10-visit limit for psychiatrist visits, there must also be a 10-visit limit for primary care physicians.
But Sheila Schuster, a mental health advocate in Kentucky with a doctorate in clinical psychology, says insurers still often "hide behind" the issue of medical necessity – denying coverage after a certain point because they deem it medically unnecessary.
"People are being told they're not going to authorize any more (psychiatric) sessions, for example," she says. "On the physical health side, you've got blood pressure readings and X-rays. But how do you measure the depth of someone's depression?"
Limiting outpatient care can backfire for insurers as well as patients, since allowing more outpatient sessions can help patients avoid an expensive psychiatric hospitalization, Schuster says.
Patrick Kennedy, a former congressman from Rhode Island who sponsored the parity legislation in the U.S. House of Representatives, says he was shocked that the printed material examined by researchers openly described differences in mental and physical health coverage. The Obama administration should require all insurance plans to disclose how they approve both medical and psychiatric claims, he says, adding that plans wouldn't be able to discriminate if those processes were open for public inspection.