This week I addressed reader questions about insurance coverage for聽mental health counseling and infertility, as well as what would happen if a state expanded its Medicaid program midyear.
Q. My son requires regular counseling from a psychologist to treat his attention-deficit/hyperactivity disorder. These聽are treated as medical specialty visits rather than general medical appointments in terms of copay requirements. Why does this coverage difference exist and is it consistent with the federal requirement that there be parity between medical and behavioral health coverage?
A. The most health plans to provide mental health and substance abuse treatment 聽as the plan鈥檚 benefits for medical and surgical care.
There鈥檚 no rule of thumb. A health plan in some circumstances under parity rules, said Alan Nessman, senior special counsel for legal and regulatory affairs at the American Psychological Association Practice Organization.
It鈥檚 called the two-thirds test. In general, a plan can鈥檛 charge a higher copayment for mental health services than it applies to two-thirds of medical/surgical services. So, for example, if a health plan applies a $50聽copayment to outpatient medical/surgical services by in-network providers at least two-thirds of the time, an insurer can charge a $50 copayment for all outpatient聽mental health services that are provided in network as well.
Q. I have gone to a reproductive endocrinologist in hopes of having a child after an unsuccessful voluntary sterilization in 2010.聽My insurer is denying coverage for treatment, even though my state, New Jersey, has an infertility coverage mandate.聽My insurer covered the initial testing, medications and visits. Why am I running into walls on this?
A. There could be any number of reasons, said Barbara Collura, president and CEO of Resolve, an聽advocacy organization for people with infertility problems. There鈥檚 no standard benefit design for infertility coverage. Some plans may deny services to people who were sterilized,聽even if the procedure was unsuccessful or has been reversed. Or an insurer may deny benefits because of a previous in vitro fertilization attempt, even if it was with a different insurer. The list goes on.
鈥淲e see a large number of denials that perplex the beneficiary, the provider and maybe even the employer,鈥� Collura said.
New Jersey is one of more than a dozen states that .聽But the mandate doesn鈥檛 apply to employers with 50 or fewer聽employees and most companies that self-insure, meaning they pay their employees鈥� medical claims directly rather than purchasing insurance for that purpose. In addition, under the New Jersey law, people who鈥檝e been voluntarily sterilized don鈥檛 meet the definition of infertile, according to Marshall McKnight, a spokesman for the New Jersey Department of Banking and Insurance.
Your best course of action is to appeal your insurer鈥檚 denial, Collura said.
鈥淚鈥檓 shocked and amazed at how often people get a denial letter, and then they file an appeal and it gets approved,鈥� she said. 鈥淚t works.鈥�
Q. If a state is expanding its Medicaid program聽in the middle of the year, does a聽marketplace plan customer with聽an income of 100 to 138 percent of the federal poverty level who is聽getting a premium tax credit have to switch to Medicaid?聽It may聽be more expensive for someone who鈥檚 already reached his out-of-pocket maximum for the year in the marketplace plan.
A. Thirty-one states and the District of Columbia to cover adults with incomes up to 138 percent of the federal poverty level (about $16,000 for one person).聽Some expansion states have imposed Medicaid premiums that are pegged to 2 percent of income as well as copayments.
If you were in a marketplace plan and you had reached your spending limit for the year, you wouldn鈥檛 owe anything out of pocket in that plan for the rest of the year. So, hypothetically, if your state imposes premium contributions and copays, it could cost more to switch to Medicaid midyear, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities. At this time, it looks as if Louisiana is on track to expand Medicaid this summer, she said.
In any case, even if a state decided to expand Medicaid this year, you wouldn鈥檛 generally be forced to switch midway through the year, Solomon said.
When you applied for coverage, if the marketplace determined that you were eligible for a marketplace plan and premium tax credits, that鈥檚 essentially a decision that you weren鈥檛 eligible for Medicaid, Solomon said, and 鈥渢hat decision can hold for the year.鈥�
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