In gun bill, boosts in coverage for mental health, substance abuse

They’re not as eye-catching as the expanded assault weapons ban or a new restriction on large-capacity magazines.

But the bipartisan agreement legislative leaders crafted in response to the massacre at Sandy Hook Elementary School also includes changes to insurance laws agreed to by both health plans and patient advocates. And they say the provisions will reduce barriers to treatment for people with private coverage.

The changes include requiring insurers to make faster decisions about whether certain urgent mental health and substance-abuse services will be covered, and making it easier for consumers to see what criteria carriers use in determining if care is covered.

Not included: Any requirements that commercial insurers cover specific services. Many patients and advocates have complained that private plans typically cover fewer mental health services than Medicaid does.

Also not included: Any move to change the way mental health services are administered for privately insured patients. Some advocates, child psychiatrists and lawmakers want private insurers to pay into a fund to pay costs and have the state administer their members’ coverage, similar to the way childhood vaccines are handled.

State Healthcare Advocate Victoria Veltri said the changes to insurance statutes in the agreement are “huge,” and “quite a move towards consumer protection.”

“Would I want even more? Sure, of course, I’m an advocate,” Veltri said. “But I think this was a very good compromise.”

Keith Stover, a lobbyist for the Connecticut Association of Health Plans, meanwhile, said the agreement preserves the process for reviewing coverage requests while ensuring that the process doesn’t become a barrier.

“I think when we look back on this important and valuable exercise that the legislature’s embarking on tomorrow, this piece will be considered a very important and valuable thing that was done,” he said.

“The payers certainly were, I think, appropriately mindful and sensitive to the general feeling in the state after Sandy Hook that Connecticut needed to feel confident that when mental health services were urgent and when substance-abuse services were urgent, for kids and adults … that the process for approval was not going to be a barrier,” Stover said.

The insurance changes are among several mental health provisions included in the agreement legislators are expected to approve Wednesday.

Other provisions include offering a “mental health first aid” program to help educators recognize signs of mental illness, doubling the number of Assertive Community Treatment teams providing intensive support to people with serious persistent mental illness living in the community, adding slots for case management for people involved in probate courts, establishing a program that provides psychiatric consultation to help pediatricians address mental health issues in their patients, and setting up a task force to study the state’s mental health system and how it serves young adults.

Lawmakers have said that one thing that became clear from hearings and discussions on mental illness since Sandy Hook was the difficulty people with private insurance face in getting coverage for mental health or substance-abuse treatment.

Veltri’s office released a report that called the system fragmented, and the legislature’s chief investigative panel released a report detailing problems privately insured young people have in getting access to substance abuse treatment.

Several of the changes in the bipartisan agreement were recommended by the Legislative Program Review and Investigations Committee in its report on substance-abuse treatment.

One of those would shorten the time insurers have to review requests for coverage of certain mental health and substance-abuse services. They currently have 72 hours. Under the agreement, that would drop to 24 hours.

The current law means that people discharged from detox facilities or acute psychiatric care might have to wait up to three days before their insurers indicate whether follow-up treatment would be covered.

Veltri said that in some cases, children or adolescents leaving detox have relapsed while waiting for their insurance companies to approve follow-up care. In other cases, families have used their credit cards to cover treatment so their children could get help immediately, rather than waiting for the insurance company to approve it or complete an appeal.

Another change legislators agreed to would increase transparency in insurance coverage decisions on mental health and substance-abuse treatment. It would designate specific criteria — such as guidelines written by the American Society of Addiction Medicine or other professional groups — that would be used in making coverage decisions.

Under current law, Veltri said, insurers can set their own criteria. Her office found that there was variation between the criteria plans used and the guidelines they said the criteria were based on. She said the agreement would allow carriers to use standards that are not the ones designated, but they would have to provide a side-by-side comparison of every component and cite peer-reviewed literature to support it, and make that information easily accessible on their websites.

“It’s a lot more transparency,” she said.

Stover said the key part of the change is that plans will have to provide easy access to an explanation of where their criteria vary from mainstream guidelines.

“You have to strike a very careful balance here between saying, ‘This is the cookie cutter that you have to use in every single case for every single situation,’ and having a situation where consumers don’t understand what the criteria are, and I think this does an excellent job of striking that balance,” he said.

The changes would not apply to everyone. State law does not apply to health plans that are self-insured, which is common among large employers.

Robert Davidson, executive director of the Eastern Regional Mental Health Board, said he’d have liked to see a proposal that would expand what private insurance covers.

“Having a serious mental illness is a rare case in which the public system is better than the private system because the private system provides inpatient and outpatient and nothing else,” he said. Private insurance typically doesn’t approve coverage for other programs and services — like residential treatment, case management, vocational services and social programs — that can help people stay stable and give them a reason to continue taking medication.

The proposal “plugs some holes and narrows others. It doesn’t address all of them,” he said. “No single proposal can, but every little bit helps.”

Follow Mirror health reporter Arielle Levin Becker on Twitter @ariellelb.

See related stories:

Recommendations made to improve access to substance abuse treatment

Report: Mental health care system fragmented, inadequate

Hearing evokes varying views of mental illness