In 2014, you can see crucial improvements in the insurance coverage for mental conditions and addictions. These improvements are nothing but the sheer outcomes of the two important steps taken by the Obama administration – including mental healthcare and substance abuse treatment within essential health benefits under the Affordable Care Act (ACA) and the final regulation of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Undoubtedly, we can say that this will affect the medical billing procedures for mental health services.
Mental Health Coverage
Essential Health Benefits (EHB)

According to ACA, health insurance must cover essential health benefits in order to be certified and offered through the health insurance marketplace. EHB comprises a comprehensive package of items and services within ten categories. The inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance (illegitimate drugs) abuse disorder are included in this package as per ACA, which includes behavioral health treatment, prescription drugs and rehabilitative and habilitative services and devices. Thus, all types of insurance plans bought through health insurance exchanges will cover mental health and substance use disorder services.

Final Regulation of MHPAEA

The final regulation of MHPAEA was published on November 13, 2013 and insists that the coverage provided for mental ailments must be comparable to the coverage for physical ailments (for example, plans are not allowed to charge higher co-payments for mental health visits than for medical visits). Although the new rule actually applies to plan years beginning on or after July 2014, the effective date for the majority of plans will be January 1, 2015 since most plan years end on December 31. Here are the major provisions of the new parity law.

  • Insurance plans are not allowed to limit access to mental healthcare on the basis of geographic region, if they do not have such a provision for physical ailments.
  • The new parity law applies to ‘intermediate’ treatment options for mental health and addiction disorders as in the case of residential treatment or intensive outpatient therapy.
  • The rules clarify that the law also applies to “intermediate” treatment options for mental health and addiction disorders, such as residential treatment or intensive outpatient therapy.
  • Insurance plans must be consistent while determining whether the treatment offered for physical or mental ailments is medically necessary and let patients and doctors know under which criteria such kind of decisions are made, which would be really helpful for resolving the hassles associated with medical billing. The plans can’t also make prior-approval procedure for inpatient mental health treatment more difficult than for admission to an acute care hospital.
  • Since the payment for psychological services under Medicare is now comparable to that for medical services, the new rule does not apply to Medicare.

However, it is still unclear how this rule applies to certain plans under Medicaid. You can file an appeal if your plan restricts mental health benefits or denies your claim unjustly. The Parity Implementation Coalition that promotes compliance with the law provides you with a tool kit at parityispersonal.org to file an appeal.

The expansion of insurance coverage does not mean everyone can easily find the care they need. A study published in JAMA Psychiatry revealed that the acceptance rates (private insurance acceptance rates during 2009-2010 were 55.3% vs. 88.7%, Medicare acceptance rates were 54.8% vs. 86.1% and Medicaid acceptance rates were 43.1% vs. 73.0%) of all insurance types by psychiatrists is significantly lower than that of physicians in other specialties. Consumers should consider the following things:

  • Check for the network of mental health professionals specified in the plan and make sure that the specified providers are in your area. Otherwise, you may have to pay high fees for an out-of-network therapist.
  • Contact your county behavioral health department if you fail to find a therapist who accepts your plan. The Federal Substance Abuse and Mental Health Services Administration provides a service locator: samhsa.gov/treatment/index.aspx in its website.

The study also says that the major reason for low acceptance rates is the inadequate reimbursement for mental health services and this may remain as a strong impediment to mental healthcare access. However, psychiatric specialists can seek help from a professional medical billing company to streamline their revenue cycle. The medical coding and billing services provided by such a company that stays updated with the new rules and regulations will ensure accurate and timely reimbursement.