Mental Health parts of my Community Blue Advantage of Western New York Contract and Procedure for Obtaining Mental Health Care and Coverage in Policy Manual

The new federal mental health parity law requires only that lifetime and I think annual (but I'm not sure) caps on total amount spent be the same for mental illness as for other kinds of illness. According to NAMI's pages on it, the employer can provide whatever sort of mental health coverage he wants (ie, if he just wants to provide counselling, no medical care at all, that qualifies), employers with fewer than I think 100 employees are exempt, employers who did not formerly provide any mental health coverage don't have to provide it now, and if an employer can show that mental health coverage will raise his premiums by more than I think it is 1%, which allegedly is actually hard to do, he is exempt from the law. Employers need only to say, "I'm not going to provide this coverage, it will raise my premiums more than 1%" - there is no provision for them to need to prove it to someone. The federal mental health parity law is most accurately described as the loopholes in the law are far larger than the law! Forget about Community Blue Advantage of Western New York's high-powered evasion of providing actual medical diagnoses and treatment to people with brain disorders, most especially the most serious ones, which is the heart of the issue with mental health parity laws to begin with!

From Section Three - Copayments.

"If you elect to receive covered services through the core Community Blue Network of Providers, you are obligated to pay the following co-payments each time the applicable service is received..."

"Except for Outpatient Acute Mental Health Visits (See Section Seven, Subparagraph "3J"), $N/A each time you receive medical services covered under Section Seven, paragraphs "2" and "3" from other Community Blue Physicians... For outpatient Acute Mental Health Visits covered under Paragraph "3J" of Section Seven, you must pay N/A % of the amount which the Physician or Provider has agreed to accept as payment in full. We will pay the remaining N/A % of the agreed upon amount."

"$N/A" and "$N/A %" is not defined anywhere in the contract as far as I can find; certainly neither in the front of the contract nor in the glossary of definitions at the end of all of the various contracts and riders. If the definition is there someplace, it sure isn't easy for the HMO member to find it!

2. "If you elect to receive covered services through Community Blue Advantage Network of Providers, you are obligated to pay the following co-payments each time the applicable service is received.

"...Except for Outpatient Acute Mental Health Visits (See Section Seven, Subparagraph "#J") and Outpatient Treatment of Alcoholism and Substance Abuse (See Section Seven, Subparagraph "3K") $20.00 each time you receive medical services covered under Community Blue Physicians or Providers in the Network...upon referral and authorization from your Community Blue PCP. ...For Outpatient Mental Health Visits covered under under Paragraph "3J" of Section Seven, you must pay 50% of the amount which the Physician or Provider has agreed to accept as payment in full. We will pay the remaining 50% of the agreed upon amount."

Section Four - Inpatient Care.

5. Limitations on Number of Days of Care. Hospital Care will be limited in the following cases:

A. Psychiatric Care. "We will pay for up to 30 days of hospitalization in a calendar year which is, in the judgement of a Community Blue PCP and subject to the approval of our Medical Director, for acute psychiatric care. Services for chronic mental health conditions are not a covered benefit. Chronic mental health conditions are mental health conditions which in our sole judgement, are not subject to significant improvement through relatively short term treatment."

I find this definition vague; are conditions that are chronic in nature, such as schizophrenia and manic depression, excluded period, or are they treated for as long as they are likely to improve significantly through relatively short term treatment? As importantly, is the visit to a psychiatrist to have them diagnosed covered, or is treatment of acute episodes covered where significant improvement can be expected with treatment, or what? It is one of a number of questions I wrote to ask Community Blue.

In any case, they don't provide for maintenance care and follow-up visits for treatment of chronic illness, which is as economically stupid as it is evil. It is so stupid, it can't even be accurately called short-sighted. They seem to be saying they would pay for 20 visits for psychotherapy or counselling, as well as for a case manager to coordinate and oversee the whole thing, but not 12 monthly visits to a doctor and the medication to pay for the treatment of a biological disease as a biological disease. It appears Community Blue of Western New York is not up on current knowledge in the insurance industry; it is far cheaper to treat brain disease effectively and as a disease then to fudge with treating it as something different. Community Blue Advantage's policy gets better.

Section Seven - Medical Services.

3. Home or Office Visits and Other Medical Services.

"We will pay for the following services by a Community Blue PCP or Provider. Except as provided otherwise, the service must be provided in your Community Blue PCP's or Provider's Office or in your home and must be provided by your Community Blue PCP or by another Community Blue Physician or Provider in the Network you have selected pursuant to a referral requested by your Community Blue PCP and approved by us..."

Notice that ALL referrals to specialists must be pre-approved by Community Blue. I called Member Services and checked on this, without mentioning mental health. Usually the PCP submits an approval request, and I was given to understand that usually approval takes about three days and is pretty much a technical matter, does the specialist participate, etc. According to the contract, Community Blue also issues standing referrals if in Community Blue's judgement continued following and treatment by a specialist is medically necessary pursuant to an approved plan of treatment. I don't get the idea this normally presents much of a hangup of referrals or of care.

J. Outpatient Acute Mental Health Visits.

"We will pay for up to 20 mental health visits in a calender year. You must pay 50% of the cost of each visit. All visits after 20 must be paid by you. Services for chronic mental health conditions (as defined in Section Four, Paragraph "5" (A)) are not a covered benefit. Payment for services for chronic mental health conditions is your responsibility."

Did they expect criticism for failure to make that clear and/or cold-blooded sounding enough, or something? Or wait - perhaps the person who wrote it has manic depression!

Notice that this does not say anything at all about case management. It doesn't say that referrals for mental health care are to be handled differently from referrals by one's PCP for any other specialty medical care.

Here is the ONLY thing in my Community Blue Advantage contract anywhere, about case management.

Section Eighteen - General Provisions

11. "Alternative Benefits. In addition to the benefits specified in this Contract, if you voluntarily participate in individual case management, we may provide benefits for services furnished pursuant to an alternative treatment plan. We may provide such alternative benefits if and only for so long as we determine, in our sole judgement, that the alternative services are medically necessary, cost effective and feasible and that the total benefits paid for such services do not exceed the total benefits to which you would otherwise be entitled under this Contract in the absence of alternative benefits. If we elect to provide alternative benefits for a member in one instance, it will not obligate us to provide the same or similar benefits for another member in any other instance where the alternative treatment is not, in our sole judgment medically necessary, cost effective and feasible, nor shall it be construed as a waiver of our right to administer this Contract thereafter in strict compliance with its expressive terms."

Notice that this passage depicts participation in case management where not specifically mandated elsewhere in the contract (as it is for diabetes, for example) as strictly voluntary on the part of BOTH Community Blue and the patient!

In a "Rider for Emergency Care, ACcess To Specialist Care, ..." which "amends the coverage available under your Community Blue Contract or Group PLan as follows", ACCESS TO SPECIALIST CARE: 3. Specialist Care Coordinator. "If we determine that your illness or condition is life-threatening, or degenerative and disabling, and will require specialized medical care over a prolonged period of time, we will authorize a referral to a specialist care coordinator, or "SCC". The illness or condition must also have reached a stage which requires specialized medical care over a prolonged period of time. This deter- mination may be made independently by us, or upon your request by contacting the Member Service Department. Your PCP may also contact the Care Management Unit on your behalf. An SCC is a specialist with expertise in treating your disease or condition, who can provide and/or coordinate your primary and specialty care. If we approve the designation of an SCC, your SCC will manage your care with regard to the disease or condition for which you are being treated by the SCC. "

This would logically appear to apply to chronic mental illness. It sure doesn't say so. It sure looks as though the contract intends not to cover chronic mental illness, even though it states that the provisions of this rider supercede what is provided in the contract.

Also, it is not clear whether referral to this specialist is voluntary; what happens if Community Blue wants the patient's care managed by a specialist the patient does not want?

This is not case management; the specialist care coordinator is defined as a medical doctor who specializes in the treatment of that condition and will take charge of treating it.

From the "Point of Service Contract". "This Contract covers health care services described in this Contract when you choose to receive the covered services from a provider (whether or not a participating provider in the Network you have selected) without having those services arranged for and approved in advance by your Community Blue PCP..."

Section Four - Inpatient hospital care.

7. Limitation on Number of DAys of Inpatient Care for Mental and Nervous Disorders. "We will only pay for a maximum of 30 days per person in each calendar year for acute inpatient hospital care in connection with mental and nervous disorders. We will reduce the number of days of inpatient care available under this paragraph by the number of days...for which benefits have been provided under your Community Blue Contract during that same calender year."

Section Twelve: Covered Medical Services.

1. Conditions of Coverage. "After the annual deductable is satisfied, we will pay for the services listed in Paragraph 3 below only if all the following conditions are met..."

3. Benefits provided.

D. Office Visits. "Except as otherwise limited or excluded, we will pay for medically necessary visits to the office of a Doctor or Other Medical Professional which we determine, in our sole judgement, are medically necessary for treatment of an injury or illness."

Limitation on Payment for Psychiatric Care.

. "We will pay for outpatient visits for mental health care provided to you on an outpatient basis by a facility issued an operating certificate by the New York State...pursuant to Article 31 of the N.Y.S. Mental Hygiene Law in a facility operated by the New York State Office of Mental Health. We will pay for Doctor and other Medical Professionals services for such mental health care when the care is provided in a Doctor's or other Medical Professional's office. Our payment is limited to an aggregate of 20 mental health visits per calendar year. However, after the yearly deductible is satisfied, our payment will be limited to 50% of our Schedule of Allowances for each such visit, instead of the 80% payment which applies to the other services covered under this Section."

These sections contain no restrictions, for instance, that treatment of "chronic mental conditions" is not covered, that were in the Community Blue Advantage contract. Does this mean that if one goes out of plan, treatment of chronic mental illness is covered? To make it this easy to get care for such common conditions totally excluded from the Community Blue Advantage contract, simply by going out of plan, with the only apparent difference being that one must meet a $250 or $240 deductible and may pay more per covered visit since the total bill may be higher since Community Blue will only pay 50% of its schedule of Allowed fee, which may not make much of a difference in the long haul if one makes more than 20 visits in a year, since only 20 visits are covered, doesn't make sense to me. I am not sure I understand correctly, and asked in the letter I wrote to Community Blue.

The one thing they did actually explain in their eventual response to me is that the point of service contract doesn't cover anything that the Community Blue Advantage contract doesn't, as they explained it, it doesn't add any coverage to what is in the managed care contract. Therefore, if chronic mental illness isn't covered in the managed care contract, it isn't covered in the point of service contract, either.

Another thing I do not understand is what is a facility operated by the NYS OFfice of Mental Health, granted a particular sort of license, etc.? This is not defined. I could not understand if my point of service contract covers only visits to state-licensed public mental health clinics of one sort and another, or it covers visits to private psychiatrists (which is who I wanted to see), or it is broader than that and includes social workers, psychologists, etc. It says, "Medical Professionals". Many sorts of mental health providers are not medical anythings. They are psychologists, social workers, psychoanalysts, etc. They are professionals, but they are not medical. I asked in my initial letter to them. Community Blue never explained to me whether I could see a private psychiatrist or needed to go to a public mental health clinic for care! That of course makes no sense - but since very little about this policy makes any sense, that hardly implies that it is not so.

This ends what is in the contract on my mental health coverage.

There actual procedure is detailed in the "Blue Book", or policy manual, on page 2.14. Notice that their procedure is completely different from what is in the contract. It appears to me to violate the contract. My primary care provider, two local Buffalo mental health advocacy organizations, and people in a support group I attended, all say that I correctly understand that Community Blue REQUIRES people to follow this procedure; it is not voluntary and one does not have a choice.

"Mental Health and Substance Abuse Treatment"

"Community Blue provides members with coverage for appropriate mental health and substance abuse care. We also make it easy for you to access that care."

"If you need mental health or substance abuse treatment, you or your Primary Care Physician (PCP) can arrange that care by calling (716) 691-2800 or toll-free (800) 723-3210. Regardless of the problem, a single phone call sets your request for treatment in motion.

"With the first call, a case manager begins evaluating your particular condition. Based on discussions with you or your PCP, the case manager finds the appropriate therapist to assess your needs and gives you the information necessary to make an appointmnt. Emergency cases, such as hospitalization, are handled immediately. Case managers help coordinate care with the hospital provider, patient and/ or family members. Case managers are available 24 hours a day, 7 days a week for emergency assistance.

If you or your Primary Care Physician (PCP) do not call to obtain prior approval for your mental health or substance abuse care, these services will be considered Out-of-Network/ Self-Referral benefits, and will be paid under your separate Point of SErvice contract. You will be responsible for any deductible and co-insurance."

In other words, to get in-plan coverage, one IS REQUIRED to call what is actually a mental health care management company, and a different one than that whose phone numbers are provided, since Community Blue Advantage changed companies just after my company enrolled in Community Blue Advantage. A case manager DECIDES WHAT YOUR PROBLEM IS, before a psychiatrist, trained to make any medical diagnosis, ever sees, you; in fact, the case manager decides if a psychiatrist will ever see you! The case manager, who I would expect holds a degree in social work or something of the sort and isn't even oriented toward seeing mental illness as a clinical entity let alone a brain disease, will channel one's evaluation and care based on what HE OR SHE decides is wrong with you. Intuitively, the entire idea is to base diagnosis and treatment decisions on cost rather than on patient's condition and needs. Further, because these case managers ARE anything but doctors, they are inherently biased against diagnosing and treating mental illness as the physical disease of the brain it so often is. But wait, are the most serious and chronic brain diseases even covered? How do these case managers handle that? I would expect that probably people who actually have very serious brain disease get channeled into 20 sessions of counselling, your coverage is up. This interpretation is supported by the fact that when I had my personnel manager call to try to get clarification of the whole thing, he was told I had to call them, and give them "more information". For what reason do they need "more information" from me to explain my coverage and procedures to access it to me? Under New York State law (and I think also ERISA) they need no such thing, and must clearly explain my coverage to me, so I wrote them a letter asking demanding answers to my questions in writing. It looks to me like the intention was to limit my coverage options before I even understand what they are!

I suspect, also, that there is some strategy to trying to get people with mental illness to get into it on the phone with them. People continually post on my bipolar lists about how they lost it completely with some intransigent case manager or clinic bureacrat with power over both whether they get treatment and whether it gets paid for. I was at the time losing it with intransigent idiots who are far less genuinely a threat to me and all that I care about than these people. Once someone goes into a full-blown rage or throws a tantrum, they lose credibility in future dealings, etc. This is part of why I refused to get into it on the phone with them. A sane person could probably have just kept telling them you aren't entitled to that, I am entitled to know this.

This policy is the best example imaginable of why the Federal law needs to be amended, as well as why New York State needs to pass its mental health parity bill. It substituted maximum number of 20 outpatient visits for maximum allowed dollar amounts, as allowed by the Federal law. It requires 50% co-payments, both in and out of network. (I had an out of network contract.) For out of network, it requires $240 deductible up front, which was impossible for me to come up with. Best of all, it specifically excluded "chronic mental illness". Many parts of the coverage are vague.

This policy, remarkable as it is, is actually pretty typical. Two good articles on the problems with managed behavioral mental health are Collins Huntly and Marian Uhlman, "The New World of Mental Health Managed Therapy is Saving Money, but its Effect on Care is Hotly Debated", Philadelphia Inquirer, Sunday Feb 5, 1995; and Iglehart, John K., Managed Care and Mental Health", New England Journal of Medicine, Jan 11, 1996, vol 334, No. 2. I found both articles at http://www.google.com by a search under something like IBM "managed mental health care" or IBM "managed behavioral health care". Iglehart says: "Health maintenance orbanizations, preferred provider organizations, and point-of-service plans, the major variants of managed care, generally provide some coverage for mental health care within their broader benefit packages, but that coverage emphasizes acute care and, in general, is quite restrictive. Most managed care plans do not cover chronic mental illnesses in their standard benefit package. A typical benfit consists of a maximum of 20 outpatient visits and 30 hospital days a year. The services available within most managed care plans are seen by mental health professionals as too limited for people with severe and persistent mental illness".

"Many health maintenance organizations contract with specialized companies that provide managed behavioral health care...The contracts with these companies are controversial because the amount of money that health maintenance organizations generally allocate for behavioral health services (3 to 5 percent on average, whereas nationally such services account for about 10 percent of total costs )is deemed insufficient. "

"Without owning health care facilities, or, for the most part, employing providers, the comapnies providing managed behavioral care have brought about a dramatic shift in patterns of use. Using case managers and reviewers-- most of whom are psychiatric nurses, social workers, and psychologists -- these comapnies oversee and authorize the use of mental health ... services. The case reviewers, using clinical protocols to guide them, assign patients to the least expensive appropriate treatment, emphaizing outpatient alternatives over inpatient care."

In fact, it is very difficult to get hospitalized if psychotic or suicidal and even harder to stay hospitalized for longer than three days to a week, and there have been a number of well publicized cases of people who died as a result. Indeed, the literature is full of tales as nightmarish as any seen on television about managed health care in general; for instance, the episode on Diagnosis Murder where a child died of a massive infection after the insurance company wouldn't authorize admission or treatment beyond oxygen, and requierd lenghthy transport to another hospital they couldn't even arrange until tomorrow, because the mother in a panic because her child stopped breathing made the mistake of taking him to the nearest emergency room, and it wasn't in the network! Psychotic and suicidal people forced to wait in emergency rooms for up to two days, sometimes to be transported elsewhere twice!

There is also a serious problem with the practice of "carve-outs" or "capitation", otherwise known as the rate at which providers of mental health care are compensated per "unit of person" (!!!) or something they treat. Austin, Texas, has the notoriously bungling and overloaded MHMR, or the state/ county mental hospital with its clinics, and then three private psychiatric hospitals, where people actually get care they are satisfied with. One of these hospitals is closing due to financial failure because of inadequate compensation, a second may close, and the third is threatened with closing. VERY funny. I checked, and the problem is not that these highly paid mental health professionals aren't getting rich enough to satisfy them. It is that the rates are so low they don't recoup the costs of say, medical equipment and blankets, forget about paying anyone!

I also had trouble with the agencies responsible for helping people with problems of this nature. Mental health consumer legal problems are handled by a program within Neighborhood Legal Services. I questioned whether Community Blue's requirement that I go through their behavioral managed care company is in fact in violation of this particular contract, whether under the Federal Mental Health Parity Law of 1996 they can cover mental health and bar "chronic mental illness", and their refusal to give me clear information in a timely manner was clearly in violation of law. After weeks of being too busy to talk to me, after a week of being told she doesn't even talk to anyone, the person in charge of that program told me she didn't have time to look into my policy, and referred me to the state insurance department. I went to talk to them, and got told the person who would know the answers to my questions wasn't there, so he was sending my "complaint" to the state office in Albany. They never acted on it. After two months I wrote to a supervisor and asked them to expedite them, on the advice of one of their supervisors, and never got a response. I had been told it was waiting in line to be assigned to someone who would even read my complaint and the policy and judge the legality of certain things about that policy - and that that takes three to four months!

It looks to me like backward Texas is far more on the ball when it comes to handling consumer problems than New York State! Certainly here there is some sort of mental health parity coverage, though I want to avoid the surprise I got when I found out that my Community Blue policy provided basically nothing, and there are also far more jobs, and ones that pay better than the job I had in Buffalo - which gives me more resources to work with than I had.