NAMI Minnesota Legislative Update
December 2, 2017Important New Findings on Lack of Mental Health Parity
A report released on Thursday by NAMI National, reveals new information about barriers that people with mental illnesses in our country encounter when trying to find affordable and accessible mental health care.
The Doctor is Out: Continuing Disparities in Access to Mental and Physical Health Care found that, despite the federal mental health parity law, people lack the same access to mental health providers as they have for other medical providers. When they seek a mental health provider, many are forced to go out-of-network with much higher co-payments than when seeking primary or even specialty care. More than 1 out of 3 survey respondents with private insurance had difficulty finding a mental health therapist, compared to only 13% reporting difficulty finding a medical specialist. Over 1 in 4 people receiving mental health therapy used an out-of-network therapist, compared to only 7% needing to use an out-of-network medical specialist.
The report also found that people had difficulty finding a mental health provider.When trying to find a provider,respondents reported the mostsevere problems as follows:
1. Providers were not acceptingnew patients (55% psychiatrist,45% therapist); or
2. Providers were not acceptingtheir health plan (56% psychiatrist, 11% therapist).
The data shows that findinga new psychiatrist was moredifficult than finding a therapist.
About one-third of respondentshad a severe problem withfinding a provider close to
home or work (36% psychiatrist,33% therapist). Respondentsremarked that many providersdid not respond to telephoneor email inquiries (29%psychiatrist, 22% therapist),
while incorrect informationin provider directoriespresented barriers for somerespondents (16% psychiatrist,15% therapist).
In a survey that NAMI Minnesota conducted, with over 60 people responding, 66% waited over one month to obtain an appointment with a psychiatrist, 15% more than four months. For a psychologist, 53% of respondents waited more than one month. When asked how difficult it was to find a mental health professional that was taking new patients, 73% said is was difficult, very difficult or extremely difficult. Comments included people stating that the initial assessment visit was set up quickly but follow-up treatment took several months another person mentioned waiting four months after discharge to see a psychiatrist, several mentioned the difficulty in finding mental health professionals from diverse communities.
NAMI Survey Results
Throughout NAMI's history, parity - covering mental health and addition care in the same WAY as other health care - has been a top priority. NAMI successfully fought for passage of a federal parity law in 2008 that was intended to improve coverage and access for mental health and substance use disorder treatment. This new report is result of NAMI National's third nationwide survey to learn whether people with mental health conditions were experiencing equal coverage and access to care under parity.
The NAMI report was released simultaneously with a report published by Milliman, Inc. on behalf of a coalition of America's leading mental health and addictions advocacy organizations. The Milliman report uses private health insurance data to confirm what everyone knows: people must seek mental health care out-of-network much more frequently than for other health care. It also confirms that psychiatrists are routinely paid less than primary care doctors and medical specialists for the same types of services - even those under the same billing codes.
Nationally in 2015, individuals received outpatient behavioral health care with out-of-network providers at a rate 5.1 times higher than for primary care services and 3.6 times higher than for medical specialty care services. For individuals receiving inpatient behavioral health care out-of-network, the rate is 4.2 times higher than for other inpatient health care issues.
In Minnesota, the disparities are glaring. In 2015, it was 8 times more likely that an office visit for mental health care would be out-of-network than for primary care. For individuals receiving inpatient mental health treatment, they were 6.19 times more likely to get this treatment out-of-network than for medical or surgical treatment.
The report also found that providers were paid less than other health care providers for the exact same billing code. In Minnesota psychiatrists were paid 47% less than primary care and other specialists for the same billing code in 2014 and that increased to over 60% in 2015.
In the 50 state analysis conducted by Milliman,Minnesota was one of the ten worst states when it came to both out-of-network office visits and in-network reimbursement rates for psychiatrists.
There are a number of factors that lead to these numbers - including a psychiatrist shortage, and flow issues for inpatient treatment - but the Milliman and NAMI reports identify significant disparities that cannot be ignored and that could be attributed to inequitable design and standards for in-network mental health providers and lower reimbursement rates making it difficult for providers to agree to be in-network providers.
NAMI National's policy recommendations include implementing routine market audits at the state level to ensure compliance with mental health parity laws. That's why NAMI Minnesota will continue to work on HF 1974 / SF 2028 to ensure mental health parity laws are enforced in our state and we will be amending the bill to include market audits. NAMI also recommends increasing rates for mental health providers, expanding reimbursement rates for collaborating care models, recruiting and contracting with a wider range of providers (including peer and family peer specialists) and promoting the use of advance practice nurses with appropriate training to prescribe mental health medications.
If you would like to learn more you can read the NAMI Reportand the Milliman report. NAMI Minnesota issued a press release and has been contacting reporters. We need to share these reports widely. Feel free to share them with your legislators as well.
The information and hard data in these two reports gives us a tremendous opportunity to better enforce mental health parity laws. NAMI is looking for people willing to share their storyto a reporter and legislators. We need people to share their personal experience and frustrations with insurance plans not covering mental health care in the same way. Here's who we are looking for:
· You are on private insurance that covers mental health care (NOT including Medicaid or Medicaid managed care or Medicare)
· You have struggled to find in-network providers, have paid more for out-of-network providers
· Insurance has not covered you or a loved one's mental health treatment.
· You are comfortable and available to develop your story and have a conversation with a reporter on short notice.
If you have a story to share about challenges finding in-network mental health treatment, please contactSam Smithas soon as possible.
Tax Bill Passes US Senate
The Senate passed their version of the Tax Cuts and Jobs Act in the early hours of Saturday morning on a51 to 49 vote, with Sen. Bob Corker (R-Tenn.) the lone Republican to not vote for the bill - no Democrats voted for the bill.This bill was passed on a very accelerated timeline and was not available to read online and was only provided to Senators a short time before debate began on the bill. So NAMI cannot yet say with any specificity what is actually in this bill. However, the broad outlines of the bill are very concerning:
Current Law / House Proposal / Senate Proposal
Medical Expense deduction available for all medical expenses that exceed 10% of gross income / Repealed / Included
Tax Exemption for Private Activity Bonds (PAB) (helps with low-income housing) / Eliminates PAB exemption / Keeps PAB exemption
ACA Individual Mandate (requires everyone to have insurance.) / Does not involve individual mandate. / Repeals individual mandate
Both the House and Senate bills will add at least $1 trillion dollars to the deficit which could result in cuts made to Social Security, Medicaid, Medicare and other programs.
NAMI is also very concerned that the Senate version repeals the individual mandate, which will lead to fewer people buying health insurance and higher rates for those who remain on the private market. Rates are very likely to increase because those mostly likely to forego seeking health insurance would be the young or healthy. This will lead to higher premiums because there will be fewer people insured and those who have insurance are likely to be older and sicker and those costs will be spread over fewer people.
The nonpartisan congressional budget office estimates that, if the individual mandate is repealed, then 13 million fewer people will have insurance in 2027 and average premiums would increase by 10% a year in the non-group market.
The Senate tax bill also threatens to initiate significant cuts to Medicare through the PAYGO rule. According to the Center on Budget and Policy Priorities, "The pay-as-you-go rule, also known as PAYGO, is designed to encourage Congress to offset the cost of any legislation that increases spending on entitlement programs or reduces revenues so it doesn't expand the deficit." If the Senate does not waive the PAYGO rule for their tax bill, Medicare could be cut by as much as 25 billion dollars a year.
Although this bill has passed the Senate, the Tax Cuts and Jobs Act still has a long way to go before it becomes law. The House and Senate will have to come together in a conference committee in order to reconcile the many significant differences between their respective bills. We will keep you updated on the movement of the tax bill and any potential impacts to people living with mental illnesses and their families.
Here is a link to an article in the Washington Postand The Hill.
Trump Administration Changing Regulations on Essential Health Benefit Set
Rule changes proposed by the Centers for Medicare and Medicaid (CMS) and Health and Human Services threaten to undermine the Essential Health Benefit (EHB) set. Under the Affordable Care Act (ACA), all plans sold on the private insurance market are required to cover 10 EHBs, including coverage for mental health and substance use disorder treatment. This reform has helped thousands of people obtain insurance coverage for their mental health care.
Under the new changes from the Trump administration, States would have additional flexibility to determine their own EHBs or to adopt the benefit set of another state. This is very concerning because it could encourage a "race to the bottom" where states offer increasingly narrower benefits. In the past, these disparities have disproportionately impacted people with a mental illness or substance use disorder.
According to analysis from the National Council on Behavioral Health, these changes could potentially limit mental health coverage in these three ways:
· Definition of Typical Employer: CMS is proposing to determine whether or not a state is in compliance with the ACA through a comparison with what they are calling a typical employer. So long as the state offers benefits that are equivalent with what is offered by the health plan of a "typical employer," then CMS will consider the state to be in compliance with the EHB requirements in the ACA. The National Council on Behavioral Health and NAMI are concerned that this will open a loop-hole where, depending on how the state defines a typical employer, it can offer fewer mental health benefits.
· Benefit Substitution:CMS rules will also allow for benefit substitution. This gives states the ability to make changes within and across the benefit categories so long as the total value of the EHB set remains the same. This potentially opens the door to coverage discrepancies. For example, a state could opt to decrease coverage for outpatient treatment in order to increase coverage for inpatient treatment.
· New Federal Default for EHBs: NAMI is concerned that any new federal default adopted by the Trump administration will offer fewer benefits, especially for mental health and substance use disorder treatment.
After failing to repeal the ACA, it is very concerning that the Trump administration is still trying to undermine Essential Health Benefits through government regulation. NAMI is opposed to any changes that weaken the EHB set.
If you would like to learn more about the CMS proposal, you can read their commentary here or look at this synopsis of how the Trump administration will determine if a State is in compliance with their EHB regulations.
News from the Federal and State Level
Concerns for Critical Access Hospitals
Congress has yet to reach an agreement on a Medicare extender deal, which refers to the provisions of Medicare that Congress must regularly renew. This issue is particularly important to critical access hospitals. According to Maggie Elehwany of the National Rural Health Association: "It's [a] little irresponsible of Congress to let the extenders expire. We're in the middle of a rural hospital closure crisis that is escalating. These payments are so critically important." NAMI shares these concerns and hopes that Congress quickly renews the extenders and CHIP funding. You can read the full article here if you would like to learn more.
CMS Proposed Medicare Changes
The Center for Medicaid and Medicare Services (CMS) proposed changes to rules on Thursday tolimit on opioid prescriptions. They also released a new mapping tool to highlight "hot spots" around the country. Read more here.
DHS Clarification Regarding the Minnesota Supplemental Aid Living Arrangement Policy
The assistance standards for Minnesota Supplemental Aid (MSA) vary depending upon the recipients income, marital status, eligibility for certain services, and living arrangement. Until now, a lower assistance rate was always given whenever the MSA recipient lived with others unless they received Medicaid home and community based waiver services, were on Group Residential Housing (GRH), were eligible for MSA housing assistance, or had a self-contained living quarters including their own bedroom, living room, kitchen, and entrance.