What happens when something that
affects children’s lives is widespread but hidden in plain sight? What if it is
something that creates untold heartache in lives that are already unnecessarily
damaged? It should be addressed and corrected. Yet, because it is hidden from
our collective consciousness it remains unaddressed, it persists, and this has
consequences.
I am referring to the plight of
countless middle-class families with children who have mental health and
substance abuse problems and who have health insurance but cannot gain access
to timely care.
Under a government
mandate called network adequacy, commercial health insurers, used by many
working, middle-class families, are required by license to offer adequate
networks of providers (child psychiatrists, psychotherapists) for families
confronting mental health and substance abuse problems. In other words, they
are expected, as per their insurance plan, to provide ready access to a
provider near where policyholders live. The reality, though, is that too often
they do not.
Why? Because commercial health
insurers that pay substandard reimbursement rates have too few in-network
providers. Their low rates of reimbursement serve as a disincentive for
providers, including community-based mental health agencies that should be
providing universal access to care, to enroll in their networks.
Consequently, many community-based agencies, along with those in private practice,
will accept only higher paying Medicaid insurance.
The gap between reimbursement
rates for commercial health insurance and Medicaid is vast. In some cases, for
example, the rate paid to providers by commercial insurers is half the rate
paid by Medicaid. Although a health insurer is expected to help families find
an in-network provider, most often they do not. They simply give them a list of
names, and few if any of those providers accept the insurance because the rates
of reimbursement don’t come close to covering the cost of services. This then
frustrates already anxious parents who have had to work up the courage to ask
for help.
It is very difficult for a parent
to pick up the phone and seek help when their child is suffering from mental
illness or addiction. When they are repeatedly turned away by their supposedly
in-network providers, who tell them “I no longer accept that insurance,” it is
devastating. When a child is denied access to timely care for mental illness or
addiction the results can be life-threatening.
A few weeks ago a mother seeking
mental health care for her teenager came to us at North Shore Child &
Family Guidance Center and told a familiar story.
"It's very hard. Decent
psychiatrists don't take new patients and the rest don't take our insurance.
Most of them don't take your insurance," she said. The intake worker asked
her how many turned her down before she called us. She said 20.
What needs to be done? The New
York State Department of Financial Services, a relatively new state agency
formed by Gov. Andrew Cuomo, has regulatory jurisdiction over insurance
companies. However, in my experience, their inaction on this issue indicates
that they do little, if anything, to monitor network adequacy.
Substandard rates of reimbursement
(e.g. the gap between Medicaid and commercial insurance rates) may be
considered a violation of the Affordable Care Act’s parity
protections, which require health insurance companies to treat annual or
lifetime dollar limits for mental health and substance abuse the same as they
do medical benefits. If that is the case, the attorney general also has the
power to address this matter if DFS will not. But what remedy is there if they
do not take action?
The New York State Comptroller’s
Office has the primary responsibility to ensure that state agencies such as DFS
are using taxpayer money efficiently and effectively. If DFS does not
investigate the issue of network adequacy, then they are open to the scrutiny
of a state audit as it relates to their effectiveness in the use of taxpayer
dollars to properly monitor insurance companies under their jurisdiction.
Although mental health
legislation, The Helping Families in Mental Health Crisis Act, has been
introduced in Congress, it will do little good if families cannot find a
provider. The act will only work when the issue of access to care is monitored
and enforced. It’s time for DFS to do its job and launch an investigation of
any commercial insurance company suspected of not having an adequate network of
providers. It could truly save lives.
Andrew Malekoff is the executive
director of the North Shore Child & Family Guidance Center in Roslyn
Heights, a nonprofit that provides comprehensive mental health services for
children from birth through age 24 and their families. To find out more, visit
www.northshorechildguidance.org. - See more at: http://nynmedia.com/news/how-insurers-are-failing-children-with-mental-health-needs#sthash.omFazlzp.dpuf
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