Managed Care - April 2008 - (Page 16) sures that health plans will continue to have the right to co-ordinate care to improve quality and lower cost,” says AHIP’s Robert Zirkelbach. Also, to offset the estimated $4.3 billion over 10 Differences years cost of the House legislation, it raises $2 bilThe Senate bill, which passed last fall and is tilion by increasing the amount that phartled the Mental Health Parity Act of 2007, maceutical companies pay the government does cover all mental diagnoses and subfor prescription drugs dispensed through stance use disorders. There are no excluthe Medicaid program for the poor. A fursions. Further, all mental health and subther $2.4 billion would come from new limstance use disorder services are covered, its on physician-owned specialty hospitals. including psychotherapy and testing, and The Senate version does not include these in all settings, including inpatient, outoffsets. patient, partial hospital, or residential treatFunding under that version is being nement settings at parity with physical health gotiated between the bill’s House and Senservices. ate sponsors, says Sperling. A health plan may deny coverage based The House parity Curiously, the leading Democratic sponon medical necessity or under the terms of proposal is too broad, contends its coverage contract with an employer. Andrew Sperling, JD, sors of the differing bills are a father and son, Sen. Edward Kennedy of Massachusetts and There is no requirement that all DSM-IV of the National AlRep. Patrick Kennedy of Rhode Island. categories be covered. liance on Mental IllIn both bills, health plans and employers Another issue of concern to health plans ness. He warns that about the House version, according to a “many employers can opt out of offering any mental health will opt out of any spokesman for the trade group America’s coverage at all, unless they are required by coverage at all.” Health Insurance Plans, is that it “fails to recstate law to provide that benefit. “We oppose the House version,” says Sperling, because “if the ognize the value of care management techniques. coverage must include all DSM-IV categories, The House version makes no mention of these which is a very wide range of disorders, many emtools, while the language of the Senate version enployers will opt out of any coverage at all and it will defeat the purpose of DEFINING MENTAL HEALTH TREATMENT the legislation.” He notes that among the conditions listed in the manual ental health parity is defined in legislation under consideration are caffeine intoxication and sleep in Congress as the provision of the same amount of mental disorders related to jet lag. health and substance abuse treatment as provided by health plans and payers for medical and surgical illnesses and procedures. In a public statement, Nicholas The Surgeon General defines mental illness as a medical term that Meyers, director of government rerefers collectively to all diagnosable mental disorders, which are health lations at the American Psychiatric conditions that are characterized by alterations in thinking, mood, or Association, which supports the behavior (or some combination thereof) associated with distress House version, said these claims and/or impaired functioning. about DSM-IV coverage are wrong. In its 2006 National Survey on Drug Use and Health, the Department “Simply because a diagnosis is made of Health and Human Services defined mental health treatment as: does not obligate insurers to pay for treatment. Insurers could still deny For adults aged 18 or older, treatment or counseling for any problem with coverage if they found that a service emotions, nerves, or mental health in any inpatient or outpatient setting, was not medically necessary.” or the use of prescription medication for treatment of a mental or emotional The Senate bill requires health condition. For youths aged 12 to 17, treatment for mental health problems is plans, including self-insured emdefined as receiving treatment or counseling for emotional or behavioral ployers, to comply with existing state problems from specific mental health or other health professionals in and federal coverage standards. school, home, outpatient, or inpatient settings. Under both versions, state parity laws are treated as the floor for is to prevent diagnosis-related discrimination by insurers. M 16 MANAGED CARE / APRIL 2008
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