Report: Mental health patients in Texas often forced out-of-network


AUSTIN (KXAN) – While a 2008 federal law was established to ensure health insurance issuers provide equal coverage of mental health or substance use disorder treatment as they would for physical care, a new report shows patients are still facing challenges in accessing services.

The Mental Health Parity and Addiction Equity Act (MHPAEA) generally prevents group health plans and insurance companies that provide behavioral health benefits from imposing less favorable coverage limitations on those services when compared to medical or surgical treatment.

A new report by Milliman, a risk management and regulatory consulting firm, shows a higher number of patients having to go out-of-network for behavioral care than for medical or surgical care. Researchers from Milliman analyzed medical claims records for preferred provider organizations (PPOs) from 2013 to 2015.

In 2015, Texas patients had to turn out of network almost five times more for in-patient addiction and mental health care compared to physical treatment.

Nidia Heston says she knows from working with other families and her own experience finding the right provider is step one in a long journey. Heston’s 15-year-old son was diagnosed with autism at age two. At age six, doctors diagnosed him with ADHD, and when he turned 10, they diagnosed him with bipolar disorder.

She says families on Medicaid often have limited options, insurance won’t cover care or sometimes providers may not take private insurance.

“A lot of providers will give you a billing form that you can submit to your insurance company, but with a lot of deductibles being – I mean, our deductible is $2,000, $3,000 – out-of-network that’s even a lot of times double that,” Heston said.

Heston said being forced out-of-network often becomes unaffordable for families.

“It’s really terrible that families have to make the choice between medications, sometimes food, electricity and finding a good provider,” she said.

Greg Hansch, public policy director for NAMI Texas, said the unequal access to treatment for people with mental illnesses is a significant challenge that can be attributed to several factors.

“There aren’t enough providers,” he said. “The insurance networks aren’t robust enough. People with mental illness often end up paying more out of pocket than people with other health conditions.”

Cathryn Donaldson, director of communications for America’s Health Insurance Plans, also points to the shortage of behavioral health providers nationwide.

“If an in-network provider is not available, health plans do cover out-of-network care as in-network,” Donaldson said. “They also actively recruit behavioral health clinicians, help patients navigate the system to ensure care coordination and monitor the availability of appointments and help members get appointments when needed.”

The Milliman report also found in 2015, behavioral health providers in Texas were also getting paid 20-30 percent less than primary care providers.

Donaldson said mental health parity doesn’t immediately translate to equal payment of providers.

“Just as provider reimbursement rates, which are negotiated between health insurers and providers, will vary on the medical and surgical side, provider rates on the behavioral health side will vary based on the health specialty, local market dynamics and the insurance provider,” Donaldson said.

“We need to be facilitating participation in the health insurance market for providers as much as possible,” Hansch said.

During the 2017 legislative session, lawmakers passed HB 10, which gives the Texas Department of Insurance the ability to enforce the federal parity law for health insurance plans under the state. The legislation also requires data collection so state agencies can compare how access to insurance benefits looks for people with mental illness in comparison to people with other health conditions.

It also formed the Mental Health Condition and Substance Use Disorder Parity Workgroup. Members of the workgroup include the Office of Mental Health Coordination at the Health and Human Services Commission, the Texas Department of Insurance and hospitals. Texans who face problems when trying to access behavioral health services can also reach out to designated staff at the Office of the Ombudsman at HHSC.

Heston encourages families to speak up if they ever have questions about mental health services.

“There are families who are willing to share their resources and how they’ve been able to manage things,” she said.

Copyright 2021 Nexstar Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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