It cost Claire Scerbak nearly $300,000 to save her son’s life.
But Scerbak said she considers herself lucky. Many Michigan families cannot afford to pay bills for loved ones facing mental health and substance abuse crises. She said her family was forced to pay for her son’s care when her insurer denied coverage.
The Traverse City mother – whose son now lives and works out of state – is among Michigan family members urging lawmakers to force insurers to pay for the kind of substance abuse treatment her son received.
A Democratic-sponsored House bill would require Michigan health insurers to cover medically necessary treatment for a mental health or substance abuse disorder the same way they cover medical and surgical services, in line with national standards. The 2008 federal Mental Health Parity and Addiction Equity Act, which sought to do the same thing, has fallen short, supporters of the House bill say.
The problem now, families say, is that insurers often deny coverage, arguing that such care isn’t “medically necessary”.
“There’s nothing in place right now that talks about, ‘What does it mean to say something isn’t medically necessary?'” said Angela Kimball of the group Inseparable, a Washington-based national organisation that lobbies for so-called parity laws.
“What we’re doing in this legislation is saying, ‘Medically necessary has to reflect what the treatment provider community says is evidence-based, effective care across the country,'” she said.
In other words, they would have to cover care as defined by accepted national guidelines, such as those from the American Association of Community Psychiatrists and the American Society of Addiction Medicine.
The bill would also require insurers to find – and cover – out-of-network and emergency services if none are available in-network. It’s sponsored by state Rep. Felicia Brabeck, D-Pittsfield Township, a longtime mental health provider.
The bill is now before the House Insurance and Financial Services Committee.
A companion Senate bill, also sponsored by Democrats, would incorporate the federal Mental Health Parity and Addiction Equity Act of 2008 into state law. By a vote of 9-1 and without debate, the Senate Health Committee on Wednesday sent that bill to the full chamber for a vote.
The 2008 federal law has long required insurers to cover mental health and substance use disorder treatment in the same way they cover other medical and surgical procedures. For example, insurers must offer the same deductibles, co-pays and out-of-pocket maximums for mental health coverage as they do for other care.
The Michigan Association of Health Plans, which represents health insurers, supports the Senate bill, its executive director, Dominick Pallone, told Bridge Michigan on Wednesday. But it opposes the House bill, calling it an overreach that will increase health care costs and “pick winners and losers”.
Requiring insurers to find and cover outside providers if none are available in-network is a difficult and costly requirement in a state with too few mental health professionals, said Brian Mills, a spokesman for the industry group.
Similarly, if there is no in-network provider offering the appropriate level of care, the insurer would be required to cover a more intensive, higher level of care.
For example, if outpatient therapy isn’t readily available in a person’s network, the insurer might have to pay for more expensive inpatient care instead, Mills said.
He said the bill is being misleadingly portrayed as a parity bill, when in fact it asks insurers to do more than is required under federal law. “This goes beyond the federal law,” he argued, in part by requiring insurers to find out-of-network care for someone.
Mills also argued that insurers do in fact cover mental health care when employers buy such coverage. It’s possible, he said, that some employers are choosing plans for their employees that don’t include robust mental health services.
“We’ve asked the (House) sponsor (Rep. Brabec) to give us some examples of situations where your clients have access issues, coverage issues, in the commercial sector,” Mills said. “We’re happy to sit down with them.”
David Lloyd, chief policy officer at the Kennedy Forum, a New Jersey-based nonprofit that advocates for state mental health parity laws, said the 2008 federal parity law alone has no teeth.
Under the federal law, “you have to prove that there’s active discrimination going on, and you have to show that exactly what they’re doing violates the very specific requirements” of the law, said Kennedy, who was in Lansing this week lobbying in support of the House bill. “It’s really hard to prove that there’s active discrimination going on.”
Michigan families have long complained that insurers repeatedly deny mental health coverage by dismissing it as not “medically necessary.
Allyson Haupt of Rochester said she fought her insurer over a $147,000 bill for temporary hospitalisation and in-home applied behavioural analysis therapy for her then-young son, who has autism.
“It took me a little over two months of fighting to get that bill overturned, and it was pretty much a full-time job in itself,” Haupt said.
Unable to regulate his emotions, she said her son would fly into rages – outbursts that grew in intensity as he got older. In first grade, he broke his mother’s nose, Haupt said in a video paid for by Inseparable.
She said the bills were eventually covered by insurance, but only after she contacted a local TV station, which contacted the company. The story never aired, Haupt said, but the insurer then told the family it would cover all but about $300 of the bills.
In July, the Biden administration proposed rules to tighten loopholes and force insurers to better document how they approve coverage to prove they are ensuring equal access to mental health care.
Haupt said her son, now 15, is better able to control his emotions.
“We were lucky that I didn’t have to work outside the home during that time,” Haupt said, referring to the hours she spent communicating with insurance representatives and trying to find care.
Haupt and other supporters of the bill spent the day in Lansing on Tuesday talking to lawmakers.
Among them was Sarah Matthews, a peer recovery coach at Live Rite Structured Recovery Corp, a nonprofit treatment centre that opened in 2019 in Roseville, near Detroit.
The centre is funded by grants that are temporary, she said. Insurance reimbursements would provide stable funding and keep the doors open, Matthews said.
“We need this in Michigan because if (people with mental health and substance abuse issues) don’t have access to services, (they) end up homeless, re-entering hospitals and re-entering jails,” she said. “We see how the services can change that.”
Scerbak, the Traverse City mother, said ensuring reliable insurance coverage for mental health and substance abuse services not only protects vulnerable patients, it saves taxpayers money spent on hospitalisation, incarceration, social services and the larger economy when the lives of people with mental illness or addiction spiral out of control.
