Under Trump, new questions about mental health benefits in Texas

As Republican lawmakers plot a full repeal of President Barack Obama’s signature health law, benefits for mental health care and substance abuse treatment for a little more than 2.6 million Texans enrolled in small or individual health plans may be among the casualties. 

The 2010 federal health law classified mental health and addiction services among the essential health benefits that must be covered by small and individual plans, without annual or lifetime caps on benefits. The law built upon 2008 federal legislation that called for large group plans to offer mental health benefits on par with other medical coverage.

More than 2.6 million Texans were covered in small and individual health plans in 2015, according to a report from the National Association of Insurance Commissioners. Before the federal legislation, health plans were not always keen to offer robust coverage for mental health treatment. Counseling sessions were typically limited, and patients who wanted more care either had to seek individual approval or pay for it themselves.

Legislative efforts to require mental health benefits parity generally enjoyed bipartisan support among state and federal lawmakers. But it’s unclear how the notion will fare under a Donald Trump presidency, and states may have to take up their own legislation to beef up protections. 

There are still notable gaps in mental health care coverage under the existing laws, according to a Nov. 15 report from the National Alliance on Mental Illness. It found that one in four of those responding to a survey did not have a mental health therapist in their health plan’s network.

In addition, the survey found that 80 percent of respondents were more likely to report difficulty finding a therapist who would accept their insurance compared to other types of specialty medical care. 

"Mental health providers often cite low reimbursement rates and heavy administrative burden as the main reasons they have chosen not to participate in health plans," according to the report. 

The report found that patients were paying more money out-of-pocket for treatment for inpatient residential and hospital stays and for outpatient care such as therapy sessions. 

Texans who feel large insurance companies are not living up to the law's requirements on mental health coverage can complain to the Texas Department of Insurance. The agency has received only a dozen complaints of alleged mental health parity violations in the last year, and only one was confirmed. 

"We recommend that consumers start with a call to their insurance company first as many issues can be resolved by talking to the company about the problem," agency spokesman Ben Gonzalez said in an email.

Because of confusing federal and state rules, it's hard for consumers with questions about mental health benefits to know where to seek answers, said Rep. Four Price, R-Amarillo, chairman of the House Select Committee on Mental Health.

“It’s a very complex issue,” Price said. “Parity sounds simple, but it’s anything but simple. That’s one thing we discovered in the process.”

The committee has not looked at how Texas’ parity laws stack up against other states, Price said, but it may do an analysis of how other states cover and enforce mental health benefits parity. For now, he said state lawmakers are limited since they “can’t usurp” federal laws with state statutes.

Jamie Dudensing, CEO of the Texas Association of Health Plans, said in an email statement that the organization “will be paying close attention” to the Trump administration’s plans for the 2010 federal health law and said health care plans are prepared to adapt.

“Texas health plans have demonstrated a long-standing commitment to pioneering innovative programs to meet the health care needs of patients with mental health and substance abuse disorders and that commitment will be unwavering," Dudensing said.

Even if the federal health law is repealed, the 2008 law requiring mental health treatment parity protections for larger health plans might remain intact.

Repealing any protections “would be turning the clocks back on mental health without question” and “opening up discrimination” for people living with mental illness and substance abuse disorders, said Greg Hansch, public policy director for the Texas chapter of the National Alliance on Mental Illness. 

Texas lawmakers have never explicitly given the state insurance department authority to enforce parity rules for small plans, he said. The department only has the authority to enforce parity for larger group health plans right now.

“If anything, it might make them more inclined to act on parity considering that," Hansch said. "If the ACA is done away with, that limits the federal government’s ability to enforce parity anymore, so now it’s like the state really does need to step in because people who are enrollees in small individual market plans wouldn’t have the federal government to turn to and register complaints."

Read related Tribune coverage:

• Texas college students who need help dealing with depression, anxiety and other mental health issues often must wait weeks to see a counselor at Texas' major public universities.
• On Friday, the president signed an ambitious plan to address the nation's opioid abuse epidemic. If fully funded, addiction treatment programs in Texas could see a surge of money.

Disclosure: The Texas Association of Health Plans has been a financial supporter of The Texas Tribune. A complete list of Tribune donors and sponsors can be viewed here.