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Mental Health Association of Maryland

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Consumer Quality Team Interviews Mental Health Consumers at Clifton Perkins Hospital

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For the first time, the Consumer Quality Team of Maryland (CQT) interviewed mental health consumers about their experiences at Clifton T. Perkins Hospital Center in Jessup, Maryland. With the addition of this hospital in January, CQT now visits all five state inpatient facilities.

Demand among patients for interviews with CQT was high, and during the course of the three-day interview process, consumers from all ten units of the hospital met with Team members to express their thoughts about the quality of mental health treatment at Perkins.

Overall, the consumers were satisfied with the services they received at Perkins. Numerous compliments were paid to the group leaders, especially the woman who leads the Tai Chi class. Consumers also praised the doctors and treatment teams, and applauded the opportunities for employment across different sectors in the hospital.

Many consumers also expressed concerns about the quality and quantity of the food served. Another reoccurring theme discussed was the way line-staff speaks to them. It was voiced that the staff could receive extra training, or be re-trained, on sensitivity and respectfulness.The interviewers reviewed their findings with the hospital’s new CEO, John Robison, and his clinical staff, who were attentive and engaged as they listened to information from the patients. The staff offered feedback and took copious notes as they were briefed on the consumers’ interviews. John Robison was appreciative of all the information, including the constructive criticism and was fast to act on it. Before the third day of interviews, dietary staff had already met with each unit to discuss the concerns about the food, and it was understood that Mr. Robison was working on a plan to improve the line staff’s communication.

CQT plans to visit Clifton T. Perkins Hospital Center again in April to hear more updates and comments from consumers after their initial visit.

Learn more about the Consumer Quality Team of Maryland here.

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Network Adequacy Series, Part IV: We need your help to ensure strong insurance networks

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On April 26, 2016, Governor Hogan signed HB1318-Health Benefit Plans-Network Access Standards and Provider Network Directories into law. This landmark legislation based on the National Association of Insurance Commissioners (NAIC) Network Adequacy Model Act will dramatically improve insured Marylanders’ ability to use their health insurance to access care. The legislation enables the Maryland Insurance Administration (MIA) to enforce network adequacy requirements. The MIA will promulgate and enforce regulations with real standards, such as limits on travel requirements and wait times for appointments. The legislation also requires the insurance carriers to improve the accuracy of the directories – no longer should there be retired doctors or wrong numbers in the online directories members use to make appointments. The insurers must also provide information to members about how they can request to see an out of network provider at the same out of pocket cost as an in-network doctor, allowing them more timely and affordable appointments.

Maryland advocates, including MHAMD, worked tirelessly through the Maryland General Assembly session to ensure the passage of this legislation, but our work isn’t over. The MIA has begun the work of drafting regulations, holding monthly hearings to allow stakeholders to provide feedback on the suggested topics. The first hearing on June 9, 2016 focused on other state and federal standards that Maryland could consider adopting. MHAMD and other consumer advocates pressed the MIA to strongly consider the Medicare Advantage standards and to look at the states that have most recently updated their standards. These states have added maximum wait times that members can be expected to wait for appointments for primary and specialty care providers. The next meeting will be held July 14, 2016, and will focus on a topic of much importance to behavioral health consumers: geographic accessibility of specialty providers.

We need your help! As we draft our comments and testify at each hearing to ensure strong regulations are adopted, we need your stories! Please contact us with any examples of having difficulty finding a behavioral health provider who accepts your insurance and is available for a timely appointment. We would love to have you share them with the MIA at the hearing, but if you aren’t able to attend, we can share them on your behalf. It is important that the Commissioner and the MIA staff hear how inadequate networks have affected you and your family.

Network Adequacy Series Posts

Network Adequacy Series, Part III: What Maryland advocates are doing

Network Adequacy Series, Part II: What are state and federal regulators doing about it?

Network Adequacy Series, Part I: What is all the fuss?

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New consumer advocate finds her voice

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A guest post from consumer advocate Jessica S.: 

As a consumer of behavioral health services for many years, it was not until I pursued specialty treatment for PTSD that I learned the depth of the injustice to behavioral health consumers done by insurance companies. It was an accepted norm that the therapy I needed would not be covered by my insurance because the network of providers available to me through my insurance company was laughably inadequate.

Upon starting treatment with my new provider I was encouraged to file for reimbursement with my insurance company and informed of my rights as a consumer to have mental health covered the same way physical health is. I began filing my claims and was denied any reimbursement by my insurance company due to a rule they were enforcing only for consumers – a requirement that all claims had to be filed within 90 days of service. The claims filing system is burdensome, so I had been saving my claims to file at one time rather than take on this tedious process. Devastated by this outright refusal to acknowledge my treatment costs, I contacted the Maryland Parity Project who helped me figure out who I needed to contact and what I needed to do to get my money. It took a long time, and it was not easy. I had to involve the Attorney General’s office and the Maryland Insurance Administration. The Health Education and Advocacy Unit of the Attorney General’s office took my complaint seriously and agreed that the insurance company was violating my rights. They were able to get the insurance to waive the 90-day requirement and after 5 months I received 1/5 of what I had paid out. It was so low due to insurance low reimbursement rates. What happened next changed my life in more ways than I have fully processed. I was asked to testify (share my story) in front of the Maryland State Legislature about my experience and the need for legislative action to prevent insurance companies from imposing such an unfair standard onto consumers.

I am a very private person, and it scared me to think about so publicly sharing that I have suffered from PTSD. I knew it was the right thing to do and that the cause was greater than my desire to stay private. Standing up for myself and sharing what I had been through just to get my insurance provider to do what they were supposed to do was so empowering. One of the most important lessons that I’ve taken with me is just that: stand up for yourself. No matter how tedious and frustrating or how the odds aren’t in your favor. I kept going with this issue and realized I was involved in something much bigger than just me. I learned that battles like this take time, and all I really had to do was not give up. They depend on people giving up and sadly many do because the barriers put in place to keep consumers from accessing care are traumatizing. After my testimony, my insurance provider decided they should reimburse me fully due to the fact that they do not have any providers within their network who could provide me with the treatment I needed (and because I called them out publicly for their despicable treatment of consumers). After 10 months, I finally received FULL reimbursement with interest.

At times I feel saddened and angry that I had to sacrifice my privacy in order to get coverage for my treatment. Not only did I have to stand before a group of legislators, but I also was later informed that many other people had access to my claims information. I feel that my privacy was severely compromised by my insurance provider. I feel so passionate about what I went through and continue to feel outraged for myself and for all suffering from mental health issues that I am continuing to speak out and work with the Mental Health Association of Maryland on addressing these issues. I am still in treatment and will have to file claims again if I want to be reimbursed for my treatment costs.

For everyone in treatment for a mental health condition please know that your voice matters. Please speak up and utilize the resources that are available to help you. Find your voice and hold insurance companies accountable for their continued discriminatory behavior towards consumers with mental health disorders.

If you are interested in getting involved in advocacy or education, sign up for MHAMD’s Citizen Action Team. To commit to five minutes of change-making advocacy per week, join the Citizen Action Team’s Commit2Five campaign. 

Posted in: Advocacy & Public Policy, Services Oversight

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Network Adequacy Series, Part II: What are state and federal regulators doing about it?

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In the first part of this series, we defined network adequacy and explained why it was critically important to ensure access to care for insured individuals. While most people agree that this issue is a top priority, there has been very little movement in some states to provide more consumer protections.

In Maryland

Maryland is one of fewer than 25 states that does not currently have quantitative standards to ensure network adequacy. In fact, Maryland is one of 14 states where the Insurance Commissioner has very little authority in this area. According to Maryland regulation, insurers determine their own network adequacy standards, the means in which they will achieve them, and corrective actions they will take if they determine that their networks are inadequate. They file these “availability plans” with the Commissioner, but the Commissioner has no authority to approve them or require improvements. Essentially, Maryland is what is called a “File and Use” state, meaning the insurers police themselves unless a consumer knows enough to file a complaint with the Maryland Insurance Administration. Maryland law enables insured individuals to go out-of-network at the in-network cost-sharing rate if there are not enough specialists in their network to provide an appointment without unreasonable delay or travel (Maryland Insurance Article 15-830d), but this must be approved by the insurance company prior to obtaining care. A member who goes out-of-network without this approval will likely be responsible for the out-of-network cost-sharing.

Other States

Recently, the National Association of Insurance Commissioners (the group of insurance regulators from around the country) spent 18 months drafting model legislation to address this issue because it was considered a nationwide problem. State regulators or advocates can use the model legislation to address network adequacy issues in their state by working with their legislature to pass the bill in their state. The Georgetown University Center for Health Insurance Reform has a great summary of the model legislation if you are interested.  The model legislation doesn’t go as far as consumer advocates would have liked, by not requiring quantitative standards such as appointment wait time and travel distances. It does, through the drafting notes, encourage states to adopt quantitative standards that work for their state. The legislation includes a requirement that the Commissioner, rather than the insurer, determine the adequacy of a plan and requires the insurers to file “access plans” with the Commissioner for each plan sold.

Prior to the release of the NAIC model legislation, many other states passed legislation or promulgated new regulations establishing quantitative standards. Families USA has a great policy brief on this issue with state examples. Of note, California regulations require carriers to ensure that consumers can access a primary care doctor within 10 days, a mental health provider within 10 days, and a specialist within 15 days. Washington has similar regulations for primary care and specialist wait times.

Federal Government

In December 2015, the US Department of Health and Human Services released the draft issuer letter to all insurance carriers who want to sell Qualified Health Plans through the Federally Facilitated Marketplaces. Tim Jost, an NAIC consumer representative, has a comprehensive summary of the letter in the Health Affairs Blog. The letter explains that Qualified Health Plans will be required to meet quantitative network adequacy standards, either time and distance or ratio based, in order to be approved for sale. The federal government will rely on state regulators in states where there are acceptable standards, and in states where there are not acceptable standards, the feds will do the review and implement standards. The standards that HHS is proposing are similar to Medicare Advantage standards, which require that 90% of individuals are within 30 minutes or 15 miles to a mental health provider.

In Part III: What are Maryland Advocates Doing? And What Can You Do?

 

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Network Adequacy Series, Part I: What is all the fuss?

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A network adequacy report MHAMD released in January 2015 sparked a firestorm of debate early in the legislative session. The finding that only 14% of the 1,154 psychiatrists listed on the Maryland Health Benefit Exchange (MHBE) Qualified Health Plan networks were accepting new patients within 45 days was widely quoted by advocates, the press and policymakers. Our study showed that in 2014, the qualified health plans have inadequate networks of psychiatrists to meet the demands of their insured members.

In this blog series, we will explore the policy topic of network adequacy: what it means, its importance for consumers, and what consumer advocates are doing to address the issue. Be sure to subscribe to MHAMD Perspectives in order to receive notification when new posts on this and other topics are available.

What is Network Adequacy?

Anyone who has had difficulty finding a doctor or specialist in their insurance network, had to travel further than they would have liked, or had to wait weeks for an appointment with an in-network provider intimately understands what network inadequacy is. The National Association of Insurance Commissioners (the group of state insurance regulators) defines network adequacy as, “a health plan’s ability to meet the medical needs of its enrollees by providing reasonable access to a sufficient number of in-network primary and specialty care physicians, as well as all other healthcare services for which benefits are included under the terms of the insurance contract.”  Essentially, insurance plans must have enough contracted doctors and healthcare providers to provide adequate access to healthcare for their members. Whether or not a network is adequate depends on the definition of “reasonable access” to care. Many states have moved to define, “reasonable” using acceptable wait time and travel distances that can be expected for an in-network appointment.

Why Does Network Adequacy Matter?

When an individual or their employer pays a premium for health insurance, they enter into a contract with the insurance company- entitling them to reasonable access to medically necessary healthcare. In order to provide this access to care, insurance companies must contract with enough providers, including specialists to meet the needs of all of their members. When there aren’t enough providers in a network, consumers experience difficulties in securing appointments, delays in access to necessary care, or much larger out of pocket costs for healthcare services. Often, especially in regards to mental health care, consumers are forced to see out of network providers, who don’t participate with private health insurance. These providers charge the consumer a market-based price for a visit, and then the consumer is responsible for getting reimbursement from their insurance company, which is often much less than the cost of the appointment. For example, an individual could pay $200 for a 60 minute psychotherapy visit with a psychiatrist, but receive as little as $50 in reimbursement from their insurance company. These out of pocket costs add up quickly- forcing consumers to make difficult choices about their healthcare.

What Can You Do?

Maryland law entitles consumers to “access to primary and specialty care without unreasonable delay or travel.” If you are having difficulty getting an appointment with an in-network mental health provider, there are steps you can take before you resign yourself to going out of network for care. Ask your insurance company to give you the contact information for a few providers who are accepting new patients and available for appointments in the next few weeks. If they are unable to do this, you can request that they provide a special case agreement, allowing you to visit an out of network provider, but at in-network cost, which could save you hundreds of dollars.

Please contact Adrienne Ellis, Director Healthcare Reform and Community Engagement at aellis@mhamd.org if you are experiencing difficulty in finding an appointment with an in-network provider and need assistance. If you have any questions about this post or want to share your story, we want to hear from you.

In the next installment- What are State and Federal Regulators Doing to Insure Network Adequacy?

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2016 Open Enrollment

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As you may know, it is currently Open Enrollment for state health insurance exchanges. The state of Maryland’s marketplace (Maryland Health Connection) is the only place where qualified Maryland residents can receive federal tax subsidies to alleviate the burden of monthly premium costs (Advanced Premium Tax Credit) and the Cost-Sharing Reduction (CSR).  In order to be considered for financial assistance, one must create an account and submit an application via Maryland Health Connection.  After inputting factors such as income and household composition, the system will determine if you are eligible for Medicaid, a Qualified Health Plan with financial assistance, or a Qualified Health Plan without financial assistance.

If you are found eligible for Medicaid, you will not be selecting a plan at the end of your application. You will have the opportunity to select a Managed Care Organization (i.e. Priority Partners) by mail or by calling HealthChoice. It may take up to 3 weeks for your application to be processed. However, any expenses you have accrued from the first of the month of application submission, you can send those bills to Medicaid to be reimbursed on a fee-for-service basis.  It is important to note that you must reapply each year to ensure you meet the qualifications for Medicaid. Be sure to look out for redetermination notices in the mail at the address listed on your application. You can apply for Medical Assistance at any time of the year.

If you are found eligible for a QHP, you will have the opportunity to select a plan that same day. Plans are listed from lowest to highest based on premium amounts. In the past, we have worked with consumers who purchased a plan with the lowest premium, the seemingly “cheapest plan.” Yet, the plan did not best cover their health care needs, and they ended up paying large amounts out-of-pocket. To avoid this situation, we have created a checklist that gives behavioral health consumers things to consider before choosing a plan and resources after plan selection. If you are currently planning to purchase health insurance, be sure to think about your current health care specialists, prescriptions, and cost-associated (premium, deductible, co-pay) with coverage. On the back of the checklist is a worksheet to help you understand how to compute plan costs.

Health insurance can be complicated to understand. For that reason, the Mental Health Association of Maryland has a Certified Navigator that can help you apply and enroll into a plan that best meets your needs. Plans and their prices have changed, so we encourage that you shop on Maryland Health Connection to ensure you have the best plan that suits your needs. You may contact Shalesha Lake at (443) 901-1588 to assist you in choosing a plan that meets your needs.

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Proposed Bill Could Potentially Decrease MD Funding

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On December 12th, 2013, Representative Tim Murphy (R – Pa) introduced the bill “Helping Families in Mental Crises Act of 2013” that aims to decrease mental health spending and increase mental illness spending. Within the 135-page document, Congressman Murphy highlights a number of changes he believes will fix the mental health system, such as creating an Assistant Secretary for the Mental Health and Substance Abuse Disorders (in the Department of Health and Human Services), fundamentally changing organizations such as Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Mental Health Services, and focusing community mental health services grants on people with the most serious mental illnesses.

With an extreme focus on a specific group of mental health consumers, individuals with less severe mental health conditions, which makes up the largest number of individuals with mental illness, and the thought of prevention are put on the back burner. The National Coalition for Mental Health Recovery (NCMHR), the National Disability Rights Network, and the Bazelon Center for Mental Health Law jointly issued a press release pinpointing how this bill will reinforce the connection between violence and mental illness, and erase the progress made in the last 30 years.“This legislation would eliminate initiatives that promote recovery from serious mental illnesses through the use of evidence-based, voluntary, peer-run services and family supports,” said Dr. Daniel Fisher, a founder of the NCMHR. The elimination of effective initiatives that prevent individuals from returning to hospitals would increase mental health spending. Bazelon Center trustee, Harvey Rosenthal mentioned “the legislation ultimately threatens to dismantle the efforts of the SAMHSA to promote recovery and community inclusion for the broad variety of people in our community.”

Another troubling aspect about the H.R. 3717 is that only states with Involuntary Outpatient Commitment language in statute will be eligible for SAMHSA block grants. IOC allows individuals with serious mental health illness to be court-mandated to follow a specific treatment plan, that will usually include medication. According to a report by the National Coalition for Mental Health Recovery, IOC programs are not effective, costly, and not likely to reduce violent behavior. In fact, voluntary programs without coercion are more effective than IOC programs. Because the state of Maryland does not currently have IOC language it statute, Marylanders could lose roughly $8 million in grant-funding if this bill passes

Representative Murphy’s bill will also cause changes in Health Insurance Portability and Accountability Act of 1996 (HIPAA). Some of the original goals of HIPAA is to assure that individuals’ health information is properly protected and to provide and promote high quality care. The pending law rolls back some of these protections and requires covered entities to treat caregivers as “personal representatives” who are entitled to obtain the individual’s protected health information with no regard to individual consent. This intrusion of personal rights could drive people away from treatment and recovery.

The Mental Health Association of Maryland currently does not support “Helping Families in Mental Crisis Act of 2013” and have urged our federal delegation to not support the legislation but instead support other legislation introduced in 2013, such as Garrett Lee Smith Memorial Act (suicide prevention; S. 116/H.R. 2734), Mental Health First Aid (S. 153/H.R. 274), Children’s Recovery from Trauma Act (S. 380), Excellence in Mental Health Act (S. 264/H.R. 1263), Mental Health First Aid Act (S. 153/H.R. 274), Justice and Mental Health Collaboration Act of 2013 (MIOTCRA; S. 162/H.R. 401) and the Behavioral Health IT Act (S. 1517, S.1685/H.R. 2957).

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