Stop "Carving Out" Insurance Benefits For Mental Health From Those Most In Need... Reform Managed Care Medicaid And Medicare In Albany And Washington

By TOM RUE, LMHC, CASAC
Choices Mental Health Counseling, PLLC

At a time when much is said in the media about a need for increased access to behavioral health care, legislative reforms that will actually work receive little attention. I applaud the efforts of reformers like Congressman Chris Gibson at a Federal level, and our local Assemblywoman Aileen Gunther (who chairs the Assembly Mental Health Committee) in Albany and others, for ongoing efforts to reform Medicaid and Medicare.

A major inequity in the current health insurance system is the fact if a person is on Social Security, mental health and substance abuse counseling are most likely designated as "carved out benefits" of managed care. This means they are not covered by, for example, Hudson Health Plan, Fidelis Care NY, or any of the other good quality plans that provide managed care Medicaid to the public (i.e. those who are not classified as disabled or otherwise covered by Medicare).

If a person has SSI or SSD (i.e. those in the community who suffer from the most severe physical or psychiatric disabilities), or is a senior citizen collecting a pension, they are most likely limited to seeking mental health or addiction counseling from a Medicare provider, which can be especially hard to find in a rural county like Sullivan. Under the present system, the majority of outpatient treatment providers are not eligible to participate in Medicare.

This longstanding inequity is neither a result of, nor is it resolved by, the controversial Affordable Care Act. (As of December 15, 2013, uninsured and under-insured New York residents became eligible to apply for health insurance through the NYS Department of Health's Insurance Exchange website, which has not been reported to have had the type of technical problems that have beset the Federal government's website for those states that have elected not to maintain their own health insurance exchange.) But like "Obamacare" or hate it, this problem is not new and has not gone away.

For a real-life example, not long ago a patient was referred to me by her gynecologist for mental health counseling due to depression and anxiety after undergoing a total hysterectomy for cervical cancer. She responded well over the months that I saw her, both to her cancer treatment and to psychotherapy. She was making progress with managing her moods and panic attacks, but suddenly had to stop her attending counseling when her application for Social Security Disability application was approved, and outpatient behavioral health became a "carved out" benefit. Even though I was a participating provider in her managed care network, only a Medicare provider was eligible for reimbursement under her policy once her SSD benefits for the cancer began. Due to her income, she was not able to afford even a reduced self-payment she was offered. She continued antidepressant medication prescribed by her doctor (which was still covered by her insurance), but told me she was not interested in switching therapists to a county or state operated clinic that could bill her "straight" Medicaid.

This gap in coverage is something I see too often. It has the unfortunate discriminatory effect of making life harder for many when they are most in need of treatment.

I get many calls many calls each month from people with managed care Medicaid asking for appointments for mental health treatment. If they have a Medicaid plan that I participate with (such as Hudson Health or Fidelis), the next question I have to ask is whether they receive Social Security benefits. Most say no, and they are offered appointments. If the answer is yes, regardless of the condition for which they are seeking treatment, they are advised to call the number on the back of their insurance card and request a referral to someone who can bill NYS Medicaid or Medicare, which are few and far between due to antiquated Federal and State laws. (See the list at the upper left column of this website for a list of health insurance and EAP plans in which I am currently in-network).

To help address this widespread problem, Congressman Chris Gibson has introduced HR 3662, the Mental Health Access Improvement Act of 2013. Anyone wishing to advocate for the rights of mentally ill and recovering people, regardless of where you may live in the U.S., are invited to click this link, or otherwise contact Congress and voice your views.

For more information, see “Seniors Mental Health Access Improvement Act of 2013,” Bipartisan Counselor Coverage Bill on the website of the North Carolina Counseling Association.

In the present environment in Washington, getting any bill out of committee and passed through both houses of Congress is a long shot, but our own Congressman Gibson and the other co-sponsors of this bill, on both sides of the isle, deserve support for this bipartisan import effort to reform Medicare by allowing expansion of the pool of treatment providers. This approach is good for the free market system, and good for consumers. They have my thanks for their efforts.

One effect of the ACA, however, will be to increase the number of people with health insurance who are seeking treatment, making licensed, qualified mental health care providers that much harder to access. This problem is described in a recent article in The Wall Street Journal, For the Mentally Ill, Finding Treatment Grows Harder: New health-care law may add to crunch for enough treatment [PDF].

In New York State, the Medicaid Institute at United Hospital issued a report in 2012 on Implementing Behavioral Health Care Reform in New York's Medicaid Program. The authors explain, "This report examines the implementation of Medicaid policy changes in New York, which will require participation in care management for beneficiaries receiving behavioral health services. Until now beneficiaries have typically received these services under a fee-for-service [i.e. "straight Medicaid"] payment model."

The Western New York Law Center reported in late August 2013 that New York State had received Federal approval to begin a trial program that would allow some SSI/SSD/Medicare recipients greater access to behavioral health, in CMS Approves Launch of Demonstration to Manage Care for All Dual Eligibles.

When these changes will be implemented locally is not clear. Provider Relations departments at managed care insurers that I have spoken with tell me they have no information about these "carve-outs" being eliminated any time soon.

However, the above described Federal and State legislation and regulatory changes offer hope that mental health and substance abuse treatment will become more accessible to those who need it most, and work toward abolishing with the existing system of "carving out" these benefits from managed care and leaving the most impaired patients to seek an appointment at a publicly funded clinic or search for a private therapist who bills Medicare.


The foregoing opinion article is posted as a form of non-partisan patient advocacy.
Linked articles and documents are provided in the public interest, for educational purposes.