Column 67 Mental Health Benefits

Column 67: Mental Health Benefits


Today is the 25th annual Ducky Derby.  In honor of the mission of the Ducky Derby, which is substance abuse prevention and youth development, I will address substance abuse benefits.

For a health plan to be compliant with the ACA (Affordable Care Act- also known as ObamaCare) it must include 10 Essential Health Benefits. According to the website, one of these categories is mental health and substance abuse services. Substance abuse is also known as substance use disorder.

Covered services include behavioral health treatment, such a psychotherapy and counseling, as well and inpatient care. Part of the ACA required that there must be "parity" between mental health and substance abuse benefits with other medical and surgical benefits.

This means in general, that limits can't be more restrictive for either type of service.  The kinds of limits covered by the protections are financial, treatment and care management.

Financial benefits would mean things like deductibles, copays, coinsurance and out of pocket limits.  Treatment benefits would be include provisions that are limiting the number of days or visits covered. Care management benefits would apply to provisions that require prior authorization before obtaining service.

When these benefit enhancements were included in the plans, like any other increase in benefits, it caused rates to increase.  It's important to understand that each time a new benefit is added as a requirement, it will increase costs.  Estimates were anywhere from 4-10% rate increases, depending on the company and the plan. Of course having all benefits unlimited now, makes it even more costly to expand categories of benefits.

When I started in the insurance business 37 years ago, many health plans had an inpatient mental health benefit with a limit of $10,000 per year or 30 days.  It was interesting to note that most every patient who was admitted under this benefit needed the full $10,000 of care.  The problem for the insurance industry became that many of the programs had very high recidivism rates.  This meant that a high percentage of members relapsed quickly.

The carriers responded with reducing impatient care to 3 days of inpatient detox and/or 20 days of counseling.  The Affordable Care Act expanded the benefits to much higher levels.  Whether these benefits will prove to be helpful remains to be seen.  These diagnoses are not like a broken leg that is simply treated and cured. These are often chronic long term situations that can require costly care and the patient may or may not be returned to a full healthy state.

Substance abuse may be tied to an underlying mental health diagnosis and the individual begins to "self-medicate".  In theory, the expansion of benefits is able to treat the underlying diagnosis, then the substance abuse can be eliminated. Or if the diagnosis is the substance abuse disorder, then that specific situation is addressed.

Substance abuse can also be tied to other factors like over-prescribing of opiates following a surgery as well as many other factors.

Unfortunately none of this is a simple problem. While we don't pretend to have all the answers, we at the Rotary Foundation Against Substance Abuse believe that our children need every opportunity to be involved in entertainment and stimulating activities that do not include alcohol and drugs. 

We believe that providing these opportunities is an investment in the future of our community.  Every child that can be saved the hell of addiction is a building block for a better community.  I hope you will participate in the Ducky Derby and invest in our youth.  They are our future.  

Note: All information in this column is provided" to the best of my knowledge" subject to final regulation by the respective agencies.