Background
Mental health is a fundamental component of overall health. Mental illness affects people of all ages and incomes and can be as debilitating as any other major medical illness. About one in five adults experiences a mental health condition in any given year. Prior to the enactment of the Affordable Care Act ( ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. ), many people with mental illness who had health insurance did not receive treatment because insurers typically placed more restrictions on coverage for mental health and substance abuse services than for other health services. For example, they imposed higher deductibles and copayments and applied lower treatment limits.
Currently, health plans provided through the state health insurance marketplaces are required to cover services for mental health and substance abuse. They must provide such benefits at parity with medical and surgical benefits. The marketplace cannot impose financial requirements or treatment limitations that are more restrictive than those required for other covered health conditions. The ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. also extended mental health parity to populations newly covered by MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. in states that chose to expand the program. Previously, only Medicaid managed careManaged care health plans with which a state contracts to deliver health services to the Medicaid population. Forty states use capitated managed care models to deliver services to Medicaid enrollees. plans were subject to parity requirements.
The ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. prohibits insurers from denying or taking away health coverage on the basis 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.
People who are not eligible for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. and cannot afford to buy health coverage on their own may be eligible for ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. -related premium- and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. subsidies that help reduce their costs. This is a significant change, given that cost is a factor often cited by people who recognize that they need mental health treatment but do not get it.
Other ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. provisions promote integrated service delivery for the mentally ill. People with serious mental illnesses die an average 10-25 years earlier than the general population, primarily due to co-occurring medical conditions and poor access to quality medical care.
Many of the ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. ’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 they do physical ailments. However, 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. Still, they must provide equivalent coverage for the diagnoses they have selected. Further, the MHPAEA does not supersede any state law that offers stronger consumer protections, benefits, rights, or remedies.
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. And 49 states and the District of Columbia have some form of parity law.
Although effective mental health treatments are available, they are not always utilized. The National Academy of Medicine has noted several challenges to providing care for mental health and substance abuse. These include stigma, patients’ resistance to treatment, and the structural and functional separation of mental health care delivery from other components of the health care system. In addition, resources—including trained geriatric professionals—for community-based mental health services are extremely limited (see also Medicare Mental Health Services).
Another challenge is that diagnostic criteria and treatments have typically been developed and validated on young and middle-aged adults and thus may not necessarily apply to older adults.
Further, long-standing efforts to deinstitutionalize mentally ill patients have not led to corresponding and necessary changes in community-based mental health care delivery. In combination with substantial reductions in mental health funding, this shift has made it difficult for many patients to obtain the mental health services they need. These difficulties are made worse by the current shortage of geriatric mental health and substance use professionals.
A 2012 report by the Institute of Medicine—The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?—found that very few providers enter, work in, and remain in the fields of primary care, geriatrics, mental health, substance use, and geriatric mental health and substance use.
MENTAL HEALTH: Policy
MENTAL HEALTH: 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.
States should ensure adequate funding for mental health and substance abuse services and develop comprehensive and coordinated delivery systems for such services.
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 who have mental health or substance abuse 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.
States should also implement initiatives such as education, training, and respite care that support family and other caregivers.
Appropriate diagnosis and treatment
Diagnostic criteria and treatments for mental health and substance abuse disorders should be validated on 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 MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. 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 careManaged care health plans with which a state contracts to deliver health services to the Medicaid population. Forty states use capitated managed care models to deliver services to Medicaid enrollees. 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, including day or visit limits and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. 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
Federally funded programs should collect and report data on the use and cost 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 grantA fixed federal appropriation that states may use at their discretion within broad federal guidelines. . 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 supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. providers.
Community mental health centers should be educated about the need to conduct culturally 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 who have mental health or substance abuse 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 mental health and substance abuse problems of older Americans. Funding should also be available for the prevention and reduction of mental disorders and alcohol or substance abuse among older adults. Research should evaluate the impact of specific therapies—especially prescription drugs—on outcomes for older patients, including individuals in nursing homes and other residential settings, those rurally isolated, and older adults with serious mental illnesses.
The Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services and the Substance Abuse and Mental Health Services Administration, through research and demonstration projects, 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 A living arrangement in which the resident is provided with a room, meals, help with activities of daily living, and protective supervision. These homes are also called residential care facilities, community care homes, sheltered care facilities, adult foster care, group homes, or… ), 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 on 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 if mental health programs are working.
Mental health coverage in Medicaid
MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. 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 ( FFSA payment model in which health care providers are paid a fee for each service furnished. It gives an incentive to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. ) plan should have access to mental health and substance abuse services, as well as physical health services, on a FFSA payment model in which health care providers are paid a fee for each service furnished. It gives an incentive to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. basis.
Quality
States should set and enforce strong licensing standards for community mental health 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 specially trained police or on-site crisis teams) 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.