Mental illness usually begins early in life: Half of all lifetime mental illness cases begin by age 14 and three-quarters begin by age 24, according to the National Institute of Mental Health (NIMH). Anxiety disorders often begin in late childhood, mood disorders appear in late adolescence, and substance abuse begins in the early 20s, says NIMH. Left untreated, one mental illness can become more severe or even lead to the development of a co-occurring mental illness.

The National Alliance on Mental Illness (NAMI) says, "The state of children’s mental health constitutes a public health crisis in this country. Currently, approximately 80 percent of children and adolescents with mental illnesses fail to receive treatment or services for their illnesses."

Furthermore, suicide is the third leading cause of death for ages 10 to 24 years, and more than 90 percent of those who die by suicide have a diagnosable mental disorder, according to the NIMH.

Getting your health plan to cover mental illness treatment can be an ordeal. Dr. Barry Herman, a Radnor, Pa., child and adolescent psychiatrist and former HMO medical director, and currently Senior Medical Director with Pfizer Inc. Medical Division, says HMOs reduce their mental health care costs by rationing treatment, pushing patients out of their networks into community mental health services and lowering their reimbursements to providers.

In addition, health plans regularly "carve out" mental health treatment by contracting with a separate company to provide behaviorial health services to plan members. Magellan Health Services and ValueOptions, for example, are large contractors for mental health treatment and other services.

Herman says this can compromise care because health plans pay these contractors on a "capitated percentage" of the premiums; that means the contractors are paid a fixed amount per plan member no matter whether the member ever uses the service or whether the member needs a lot of service. Herman says this arrangement encourages rationing and cost-shifting.

"It's very hard for parents to get the appropriate treatment for their children under managed care," says Herman. "It's a shell game all about cost-shifting rather than about good patient care. Many diagnoses specific to children and adolescents, such as attention deficit and hyperactivity disorder and eating disorders, are excluded from coverage. These kids fall through the cracks."

Additionally, Herman says it is an abomination that parents and their children must endure long waits for appointments, endless pre-authorization requests for mental health care, and claim denials.

Andrew Sperling, Director of Legislative Advocacy for NAMI, says carve-out programs have the potential to provide better care than the health plans would on their own. He points out that "clinical staff have more experience with children and adolescents and, by design, their plans monitor quality and treatment plans and outcomes." Sperling also says paying on a capitated basis encourages carve-out programs to provide early-intervention care rather than waiting until a patient has deteriorated to the point of needing hospitalization.

Treatment through SCHIP

If your child qualifies for your State Children's Health Insurance Program (SCHIP), you can receive some mental treatment coverage or your child. However, Sperling notes that Congress passed the SCHIP law allowing mental health coverage limits of 75 percent of the "actuarial value" of medical and surgical coverage. That means, once again, that mental health coverage gets the short shrift. "And that's not good," says Sperling.

Become an advocate for your child

Parents must become educated consumers in order to get the mental health care help from HMOs their children need. If your claim is denied or payment reduced, "appeal everything," says Herman, and as many times as it takes to secure the appropriate medically necessary care. If your insurer rebuffs your attempts, and you believe your plan's terms provide coverage for what you want, initiate an appeal directly with the insurer. In addition, the best places to take your complaints are:

• Your state insurance department.
• Your state legislators.

Mental health parity laws

What's needed, above all, is a federal mental health parity law, says Sperling. Currently, health plans can and do impose benefit limits on mental health treatment that are below the limits of regular medical care. Sperling says these "arbitrary limits" on benefits such as in-patient hospital days and out-patient visits are barriers to quality care.

Mental health parity laws require that health plans provide coverage for mental health treatment that's equal to medical and surgical benefits. Some states have enacted their own mental health parity laws, but a federal law has yet to be enacted. By March 2008, the U.S. Senate and House had both passed their own versions of mental health parity bills. Their final fate is yet to be determined.