Behavioral Health

ACA Plans Deny 18% of Claims in 2020; Enrollees Rarely Appeal

About 18.3% of in-network claims were denied by non-group qualified health plans (QHPs) offered on in 2020, according to a recent Kaiser Family Foundation analysis. Among the 144 issuers in states with complete data on claims received and denied, 52 of them had a denial rate between 10% and 19%. In 2020, the majority of denials (72%) were classified as “all other reasons,” while one in five of the roughly 765,000 medical necessity denials involved behavioral health services. In addition, of the more than 42 million denied claims in 2020, marketplace enrollees appealed fewer than 61,000 claims — a 0.1% appeal rate — and insurers upheld 63% of denials that were appealed.


Poor Mental Health Care Access Increases Systemic Costs

Health insurers have long struggled to administer behavioral health benefits, which won’t get easier any time soon: Demand for mental health services is high due to the opioid crisis and the mental health strains of the COVID-19 pandemic. Experts from clinical, financial and policy backgrounds say that coordinating behavioral health care with traditional medical benefits — and bringing behavioral health care providers into insurer networks — are both essential to managing costs and ensuring access to care.

Despite decades of policymaking that has attempted to streamline access to mental health care benefits, most notably through mental health parity, mental health care remains expensive and hard to access. (Several federal laws mandate mental health care parity: Health plans are not allowed to impose benefit limitations on mental health care that are more severe than limits placed on medical and surgical benefits.) What’s more, mental health care providers are usually siloed from other clinicians on a patient’s care team, which tends to exacerbate medical conditions and increase costs.


Mental Health Care Access Varies Across Demographics, Insurance Coverage

One in four adults reported symptoms of anxiety and/or depression prior to the COVID-pandemic, according to a Kaiser Family Foundation analysis of the National Health Interview Survey in 2019. While the rates of people reporting mental health symptoms across racial and ethnic groups are similar, a much larger share of Black adults with moderate to severe symptoms did not receive treatment. Meanwhile, uninsured people were significantly more likely to not receive mental health care (62%) compared to their insured counterparts (36%). Since the pandemic began, more people suffered from poor mental health, with one-third of adults reporting anxiety and/or depressive disorder in February 2022.


HHS Seeks Funding to Promote Mental Health Parity, Free Visits

The Biden administration’s proposed budget includes an ambitious mental health care agenda that would step up enforcement of mental health parity, change medical necessity standards and require expanded mental health benefits. Though the budget is only a proposal and must pass Congress, where it will be heavily modified, the document arrives at a moment when legislators in both parties have made expanding access for behavioral health care a central element of their responses to the COVID-19 pandemic and opioid misuse epidemic.

The administration’s proposed 2023 HHS budget in brief includes several notable behavioral health proposals that would impact commercial insurers. That list of proposed policies includes stepped-up behavioral health parity enforcement, more funding for Medicare and Medicaid behavioral health benefits and a requirement that all health plans — including commercial group plans backed by employers — provide three behavioral health visits per member every year without charging any cost sharing.


AHIP Will Prioritize Telemedicine, Health Equity Post-Pandemic

On Feb. 23, health insurer trade group AHIP hosted a virtual State of the Industry presentation, reviewing progress made in 2021 and important issues for the health insurance industry as it looks to a world beyond the COVID-19 pandemic.

Matt Eyles, president and CEO of AHIP, opened the conversation with a look at the organization’s 2021 initiatives and hopes for 2022. Eyles stressed the importance of the No Surprises Act, which aims to protect consumers from surprise medical bills. The legislation went into effect on Jan. 1, but it is currently the subject of a number of lawsuits filed by organizations including the American Hospital Association and American Medical Association. “AHIP continues to fight and protect the law,” Eyles said during the presentation.


Feds Take Aim at Insurers’ Compliance With Mental Health Parity

A new biannual report to Congress from HHS and the departments of Labor (DoL) and Treasury has found that carriers and plan sponsors are generally not in compliance with recent regulations requiring health plans to document the level of access plan members have to mental health care. Experts say that carriers are largely to blame, but plan sponsors also need to make a greater effort to hold insurers accountable and meet new federal reporting requirements.

Several federal laws mandate mental health care parity: Health plans are not allowed to impose benefit limitations on mental health care that are more severe than limits placed on medical and surgical benefits.