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Insurers have ignored mental health care despite a law prioritizing it. State Dems want to change that. 

Mental gymnastics

click to enlarge Drug needles found during a clean-up of a local homeless camp. Treatment is scarce. - COURTESY DEE CUNNINGHAM
  • Courtesy Dee Cunningham
  • Drug needles found during a clean-up of a local homeless camp. Treatment is scarce.
Coloradans aren’t getting proper mental health care.

That’s not just an opinion — according to the law, it’s a fact. The federal Mental Health Parity and Addiction Equity Act of 2008 was supposed to ensure that insurance carriers prioritized behavioral health (which encompasses mental health and substance use treatment) on the same level as physical health. But in Colorado, as in most other states, that’s not happening.

In 2015, people here were seven times more likely to go out-of-network for behavioral health treatment than for primary care, a 2017 Milliman report found. The same report found that Colorado’s behavioral health providers were reimbursed 40 percent less by Medicare than primary care providers. That’s despite the fact that the state passed its own parity law back in 1997.

The latest effort to address the problem is a bill backed by nonprofit Mental Health Colorado. Titled “Behavioral Health Care Coverage Modernization Act,” House Bill 1269 is intended to strengthen enforcement of parity laws for both commercial insurers and the state’s Medicaid system, with the goal of making sure Coloradans can get mental health and substance-use help just as easily as physical treatment.

“There’s a lot of stigma around mental health, and to the degree that we support it and treat it just like we treat physical health ... that’s going to help diminish the stigma,” says Rep. Lisa Cutter, D-Littleton, who sponsored the bill along with Rep. Tom Sullivan, D-Centennial, and Sen. Joann Ginal, D-Fort Collins.

The 24-page bill, introduced March 25, lays out a daunting agenda. Principally, it specifies that both commercial carriers and Regional Accountable Entities, or RAEs (the contractors that provide care for the state’s 1.3 million Medicaid clients) must cover the prevention, screening and treatment of behavioral health disorders. It also requires carriers and RAEs to maintain an adequate network of doctors, counselors and therapists, and to authorize out-of-network treatment when in-network providers aren’t available.

What if there just aren’t enough providers to go around? In 2013, the last time the community collected data on psychiatrists, there were only 9.1 practicing for every 100,000 people in the Colorado Springs metropolitan area, and experts say that shortage — driven by a combination of factors, including low reimbursement rates — has probably gotten worse.

But Nancy VanDeMark, the interim CEO of Mental Health Colorado, says carriers have a responsibility to make sure their networks are adequate.

“The workforce shortage is real,” she says, “but there’s more that can be done from the carriers’ perspective and from the Medicaid perspective to expand the behavioral health workforce.”

While House Bill 1269 doesn’t include provisions to specifically address the shortage, VanDeMark believes that strengthening incentives for providers in underserved areas, and eliminating barriers for providers to join Medicaid and commercial networks, could help.

And if there aren’t enough providers in the network, she notes, the bill would mandate that carriers cover out-of-network treatment.

The bill packs a punch by mandating that the state commissioner of insurance refuse a rate increase for carriers that don’t provide adequate behavioral health care. It would also require carriers to submit an annual report to the commissioner illustrating they’re in compliance with parity law.

Several other provisions included in the bill would make it easier for people with substance use disorders to receive medication-assisted treatment, a “well-researched and highly effective form of treatment for opioid use disorder,” VanDeMark points out.

While House Bill 1269’s prime sponsors are all Democrats, VanDeMark says Mental Health Colorado is confident it will garner bipartisan support. “We don’t believe that it’s a particularly controversial bill, because it really is not creating much new burden,” she says. “It’s really ... making sure that there’s clear avenues for enforcement of existing laws.”

And some Republican opponents of the “red-flag bill” — which authorizes law enforcement to remove firearms from people who pose a danger to themselves or others — have said that legislators hoping to reduce the suicide rate should instead look at repairing the state’s mental health system.
That system has certainly experienced its fair share of issues. Since the federal parity law was applied to state Medicaid plans in 2013, and Colorado expanded its Medicaid program the following year, advocates have heard from patients who waited weeks or months to get an appointment, and from providers who didn’t get reimbursed for care.

In July, the state moved to make changes in the way it delivered Medicaid care that were supposed to improve the system. AspenPointe, which formerly held the Colorado Springs area’s Medicaid contract for behavioral health care, handed those responsibilities over to a new Regional Accountable Entity, the Colorado Community Health Alliance (CCHA).

That change came with growing pains, VanDeMark says.

“I have heard that in particular CCHA struggled with provider payments early in their contracts, and it took them some time to get some of their administrative functions up and running,” she says.

However, VanDeMark says she’s heard from consumers and providers that the system has improved in some ways since CCHA took over from AspenPointe.

“The feedback that we’ve heard … is that the access to services is better than it was before and that providers are having an easier time getting enrolled in the networks,” VanDeMark says. “So I do think some of it’s growing pains, and obviously Mental Health Colorado believes that we have a role in holding these contractors and the state accountable.”

One way that Mental Health Colorado hopes to improve accountability is through the behavioral health ombudsperson’s office, created through bipartisan state legislation passed last year. The office will soon begin fielding complaints about inadequate coverage for mental health care and substance use treatment.

Colorado Springs’ own Sen. Bob Gardner, a Republican, sponsored that legislation — and he’s demonstrated a willingness to work across the aisle on mental health.

Another bill of Gardner’s, which he’s sponsoring with Sen. Rhonda Fields, D-Aurora, would create the Office of Children and Youth Behavioral Health Policy Coordination at a cost of $1.3 million to multiple state agencies. As of the Indy’s deadline, on the morning of April 2, Senate Bill 195 had been approved unanimously by the Senate Appropriations Committee and was headed to the Health & Human Services Committee.

The bill would appoint a 15-member commission to work with the Department of Health Care Policy and Financing to implement wraparound mental health services for at-risk kids. The commission would also develop a standardized behavioral health assessment.

For Gardner, who represents a county with a suicide rate that’s 1.12 times the state average (and 1.6 times the national average), mental health ranks high on the priority list.

“The impetus for me, the reason I’m engaged on all of these bills, is we have serious youth mental health issues,” Gardner says. “We have an alarmingly high teen suicide rate in El Paso County. One is too many, but our rate is alarmingly high.”

For that reason, Gardner says, he supports the concept of House Bill 1269, with the caveat that making carriers comply with parity is “certainly more complex than it seems when you just talk about it in the abstract.” But the alternative not only limits access to care, but also leaves the state legally liable, he points out. Other states have faced lawsuits because their mental health coverage isn’t up to par with federal parity laws.

The Department of Health Care Policy and Financing, which manages the state’s Medicaid system, hasn’t taken a position on HB1269, says spokesperson Marc Williams. The department will wait until it sees the fiscal note describing how much the bill’s implementation will cost. (As of April 2, that note had not been finalized.)

Rep. Cutter says the bill’s principal cost would be employee compensation.

“In the scheme of fiscal notes, it should not be overly ginormous,” she says. “We’ve worked really hard to keep it reasonable.”

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