How insurers are failing children with mental health needs

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.