Getting mental health treatment coverage for children

By Insure.com

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.

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According to a recent article by U.S. News & World Report, between 8 and 13 million children and teenagers have a mental health problem at any given time. Unfortunately, two-thirds of them are not getting treatment for their mental health issues.

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.

Mental health insurance for children

Getting your health insurance plan to cover mental illness treatment can be an ordeal. Dr. Barry Herman, a child and adolescent psychiatrist and former HMO medical director and currently Area Medical Officer at Sanofi-Aventis U.S., 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 insurance plans regularly "carve out" mental health treatment by contracting with a separate company to provide behavioral 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 whether the member never uses the service or uses the service heavily. 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 the National Alliance on Mental Illness (NAMI), says carve-out programs have the potential to provide better care than the health plans would on their own. “These carve-out plans have greater expertise in mental health treatment services than most managed care plans. They will continue to exist, and in fact, we could see the market strengthen. Because of uncertainty many plans have about complying with the 2008 parity law [see below], we expect that many states will turn to HMOs because of their expertise in mental health treatment.”

Coverage through CHIP

If your child qualifies for the Children's Health Insurance Program (CHIP), you can receive some mental treatment coverage or your child. The first step to determining whether your child qualifies is to check into income eligibility requirements in your particular state.  

Become an advocate for your child

It’s important to educate yourself about the mental health assistance available for your children from HMOs. 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.

In 2009, a new law for the Children’s Health Insurance Program went into effect, expanding health coverage to 4 million additional children and requiring that they receive the same access to treatment for bipolar disorder, anxiety, depression and other mental health disorders as they do for physical health issues.

Problems despite coverage

There are still a few problems, Sperling notes. “In some communities there is a severe shortage of child psychologists. It’s an issue of capacity that parity cannot solve on its own—we need more experts in child psychology. What we see is, unfortunately, many pediatricians are trying to treat these disorders because the family doesn’t have access to a specialist in the community.”  

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