AARP Hearing Center
Background
Mental health is a fundamental component of overall health. Mental health conditions and substance use disorders affect people of all ages and incomes and can be as debilitating as any other major medical illness. About one in five adults experience a mental health condition in any given year, and many experience physical and mental health conditions simultaneously. Older adults often face unique challenges that can impact their mental health, such as increased risk for multiple chronic conditions and loss of social connections.
Health plans provided through the health insurance marketplaces are required to cover services for mental health and substance use disorders (also called “behavioral health” disorders). Insurers cannot impose financial requirements or treatment limitations that are more restrictive than those required for other covered health conditions. The ACA also extended mental health parity to populations newly covered by Medicaid in states that chose to expand the program. Previously, only Medicaid managed care plans were subject to parity requirements.
The ACA prohibits insurers from denying or taking away health coverage based on the presence of mental illnesses. It also ended lifetime and annual limits on the dollar value of benefits, which helps reduce out-of-pocket expenses for individuals with long-term service and medication needs.
Many of the ACA’s parity-related provisions augment the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The MHPAEA requires group health plans for businesses with 51 or more employees to cover mental illnesses and substance abuse at the same level as physical ailments. These provisions only apply to plans that choose to offer mental health and substance abuse coverage. The law does not require plans to cover all mental and substance use disorders, but they must provide equivalent coverage for the diagnoses they cover. MHPAEA does not supersede any state law that offers stronger consumer protections, benefits, rights, or remedies. Despite the law, however, recent evaluations have found that many health insurance plans are not providing parity in mental health and substance use disorder benefits.
The Federal Employees Health Benefits Program, the world’s largest employer-sponsored health insurance program, requires parity between mental health benefits and benefits for other conditions.
Mental health conditions are frequently underdiagnosed and undertreated among older adults. Scientific evidence on the validity of screening tools for other mental illnesses among older adults is often lacking, which could lead to older adults not being diagnosed or being misdiagnosed. Many barriers prevent older adults from accessing high-quality behavioral health care, including:
- Behavioral health provider shortages, which lead to issues like limited provider options and long waits for patients. There is a lack of mental health professionals trained in geriatric mental health care in particular.
- Behavioral health care coverage gaps, particularly in Medicare (see also Medicare Mental Health Services).
- Inadequate behavioral health provider networks and out-of-date provider directories.
- Stigma and ageism.
- Separation of behavioral health care delivery from other components of the health care system.
- Limited resources for community-based mental health services.
- Lack of clinical research specifically on the older adult population that could help providers better treat and diagnose older adult patients with mental and behavioral health problems.
There are also longstanding racial and ethnic disparities in mental health care access and treatment. In addition to addressing the barriers listed above, efforts such as diversifying the workforce, addressing implicit bias among providers, and improving language access could help reduce access disparities.
MENTAL HEALTH AND SUBSTANCE USE DISORDERS: Policy
MENTAL HEALTH AND SUBSTANCE USE DISORDERS: Policy
Access to services
The National Academy of Medicine’s recommendations on improving the quality of the overall health care system should be applied to mental health and substance abuse settings but tailored to reflect the distinct characteristics of such care. In particular, evidence on effective treatments and services specific to diverse older populations should be synthesized and disseminated. The competency, capacity, and diversity of the workforce must be strengthened.
Federal and state governments should ensure adequate funding for mental health and substance abuse services for older adults. They should also develop comprehensive and coordinated delivery systems for such services.
Federal and state governments should work across agencies to support building and retaining a robust and diverse mental health workforce.
Efforts to reduce prescription drug abuse must ensure appropriate access for patients with legitimate medical needs.
Policies are needed for those in managed care plans with mental health or substance use disorders to ensure their access to necessary services, including emergency services and mental health specialist care.
States also should ensure that both private and public mental health and substance abuse services meet high standards for quality. States should monitor the public’s access to and satisfaction with services and protect clients’ due process rights. They should involve consumers, their family members, advocates, mental health coalitions, and professionals in planning, implementing, and evaluating services.
Finally, initiatives such as education, training, and respite care that support family and other caregivers should be implemented.
Appropriate diagnosis and treatment
Diagnostic criteria and treatments for mental health and substance abuse disorders should be validated in older adults.
Adequate and affordable coverage
Federal and state governments should support proposals to require adequate and affordable mental health and substance abuse coverage. For example, the use of Advanced Practice Registered Nurses to provide some services to Medicaid patients may increase access to mental health services and also prove cost-effective.
Mental health services should have parity with (i.e., be covered at levels equivalent to) other health services.
Federal and state governments should rigorously monitor and enforce parity requirements in individual and group market plans as well as in Medicaid managed care programs, benchmark, and benchmark-equivalent plans.
Costs
The Department of Labor should rigorously monitor and enforce the Mental Health Parity and Addiction Equity Act (MHPAEA), particularly with respect to ensuring that businesses accurately estimate implementation costs. Congress should ensure that restrictions on mental health and substance abuse services in health plans not addressed by the MHPAEA do not exceed those for physical health services. This includes day or visit limits and cost-sharing levels.
States should ensure parity beyond the provisions of the act for all plans providing mental health and substance abuse services.
Data collection and reporting
Federal- and state-funded programs should collect and report data on the use, cost, and quality of mental health and substance abuse services for older people, including people enrolled in managed care plans.
Showing cause for coverage denials
Insurers should be required to show cause before denying payment for specific medications prescribed by a physician to manage a mental health condition or substance use disorder. Physicians should determine which medications are more effective or medically appropriate, even if they are different from the insurer’s recommended substitute.
Funding for community-based providers
The federal government should increase funding for community-based mental health and substance abuse services through the mental health block grant. A larger portion of funds should be targeted toward nontraditional providers of services for the older population. Services should include adult day service centers and other community-based long-term services and supports providers.
Community mental health centers should be educated about the need to conduct culturally and linguistically appropriate outreach to older adults. Because older adults typically will not self-refer, services should be provided at other sites and affiliations established with area agencies on aging.
Managed care
Protections are needed for those in managed care plans with mental health or substance use disorders to ensure their access to necessary services, including emergency services and mental health specialist care.
Policymakers should evaluate managed behavioral health care to assess whether enrollees have access to appropriate, high-quality, and timely care.
Research
Additional funding should be made available for research on the complex epidemiology of older Americans’ mental health and substance abuse problems. Funding should also be available for the prevention and treatment of mental health illness, and substance use disorder among older adults. Research should evaluate the impact of specific therapies, including prescription drugs, nonpharmacological treatments, and other emerging treatments on outcomes for older patients, including individuals in nursing homes and other residential settings, those living in rural areas, and older adults with serious mental illnesses.
Through research and demonstration projects, the Centers for Medicare & Medicaid Services and the Substance Abuse and Mental Health Services Administration should encourage innovative delivery models for mental health and substance abuse services (e.g., integrated care). They should bring services into homes, senior centers, residential care facilities (including board and care homes), and federally assisted housing sites.
Policymakers should support ongoing research to evaluate the impact of specific mental health and substance abuse services on patient outcomes and the use of other health services and behavioral health systems, including various types of carve-outs. Evaluations should examine access (e.g., timely service and an array of appropriate services), enrollee satisfaction, outcomes of care (e.g., the ability to live independently), and systems integration (e.g., tracking in other systems, such as criminal justice and education) to determine whether mental health programs are working.
Mental health coverage in Medicaid
Medicaid law and regulations should provide for payment at adequate rates for mental health and substance abuse services. Individuals should be able to choose the same delivery system for mental health and substance abuse services as they do for physical health services. For example, individuals who select a fee-for-service (FFS) plan should have access to mental health and substance abuse services, as well as physical health services, on an FFS basis.
Quality
States should set and enforce strong licensing standards for community mental health and substance use disorder treatment centers.
Prisons
States should improve mental health and substance abuse services in criminal justice settings through increased funding and better collaboration with the larger mental health system. For example, states should establish jail-diversion programs (possibly through the use of on-site crisis teams with mental health professionals) to minimize the number of seriously mentally ill individuals who are inappropriately incarcerated. Inmates with a serious mental illness should receive psychiatric and substance abuse services while in jail and follow-up care upon release.