ProPublica series on barriers to behavioral health coverage

ProPublica published a series of articles highlighting the insurance barriers to mental health and addiction care: America’s Mental Barrier: How Insurers Interfere With Mental Health Care. The articles cover a variety of barriers and problems, summarized below.

Although federal law (parity) requires insurers to provide the same access to mental and physical health care, insurers frequently restrict coverage and delay or deny care for mental illness. Insurers can set their own standards for determining what to pay for, and this is often determined by financial interests, rather than patient interests or clinical expertise.

Behavioral health providers often decide not to participate in insurance networks, due to insurers interfering with patients’ care, the dysfunction of working with insurers, and it being financially unsustainable. It is often insurers, not therapists, that determine who can get treatment, what kind they can get, and for how long. Providers report struggling to stay in business as insurers withhold or delay reimbursements, which are too low to pay for care provided.

Millions of Americans get trapped in “ghost networks,” unable to access care from providers listed in their insurer’s network. Providers may be listed in a network but have retired, died, stopped accepting insurance, stopped taking new patients, etc. It is effectively a “bait and switch” by insurance companies that leads customers to believe there are more options for care than exist. Insurers have not been held accountable and have little incentive to closely monitor directories. It has fallen to researchers and secret shopper surveys to reveal the pervasiveness of directory errors.

Some states are starting to implement stronger protections, including defining the clinical standards that insurers must use when making coverage decisions for mental health and/or addiction care, regulating how insurers conduct utilization reviews of behavioral health care, requiring insurers to report how much access to behavioral health care they really provide, or working to address ghost networks. But requirements, monitoring, and enforcement continue to be lacking.

There are nowhere near enough available providers in insurance networks to serve all of the people seeking care, and even though almost all Americans are insured, many are still unable to access care.

See the full ProPublica series for personal stories on how these barriers affect individuals, state-specific findings, and tips from experts for evaluating insurance plans and taking recourse for inadequate behavioral health networks.