A new Colorado law that requires insurers to reimburse behavioral health care providers for mental conditions on par with compensation for physical conditions left a gap that advocates fear will make it harder for the state’s poorest and most complicated patients on Medicaid to get optimal care.
The sweeping overhaul, signed into law by Gov. Jared Polis last year, was meant to create parity in care for the mentally ill, and supporters say it significantly strengthened coverage.
While the new law puts detailed requirements on private insurers regulated by the state for what are called dual-diagnosis cases, legislators balked at an estimated $68 million annual price tag on requiring the same from the state’s Medicaid program. Advocates worry this could create two tracks of care, one that addresses dual-diagnosis challenges for some, while the poor still battle to overcome bureaucratic hurdles.
Rep. Lisa Cutter, a Democrat from Littleton, said the compromise was made to help build consensus. She noted that the bill made improvements across the board and said she wants to continue fixing problems where they become apparent.
“For both people who have private insurance or public insurance, this bill made strong steps forward in ensuring they receive the behavioral health services to which they are entitled and that they are not denied coverage simply because they have a behavioral health condition,” Cutter wrote in an emailed response to questions about the dual-diagnosis provisions. “Legislating involves difficult decisions, and we knew this bill was the first step in making progress on this critical issue. I will closely monitor how this bill is working, and I am committed to ensuring that Coloradans have access to the care they need.”
For dual-diagnosis patients, a mental health condition, like depression, anxiety or bipolar disorder, is accompanied by another condition, which could be neurophysiological, like cerebral palsy, dementia or a traumatic brain injury, or physical, like deafness or drug addiction-related.
Individuals with dual-diagnoses, also called co-occurring conditions, often are bounced like pinballs between health care providers who might specialize in one, but who direct the patient elsewhere for the other. Having multiple providers can be complicated by coverage denials, often because part of the diagnosis isn’t deemed “medically necessary.”
The new law requires state-regulated health insurers to treat any mental health need that appears as part of a dual-diagnosis and which is included in any of three diagnostic manuals: the Diagnostic and Statistical Manual of Mental Disorders, the International Statistical Classification of Diseases and Related Health Problems or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.
But for Medicaid, the state-run health insurance program for low-income individuals, language about co-occurring conditions only applies to “covered treatments for covered behavioral health diagnoses.” Because Medicaid determines what is covered, mental health advocates think the new law could still allow the state to deny or diminish some services dual-diagnosis patients need.
One Boulder-area father struggling to help his son said they’ve experienced how Medicaid can cause problems for dual-diagnosis patients. John Smith, whose name has been changed, said the dual-diagnosis nature of his adult son’s mental health and substance abuse conditions has complicated his treatment. Although Smith thinks the state’s Medicaid program did an adequate job meeting his son’s needs a few years ago, he said that lately the program has made things harder.
Smith’s son began having mental health problems during his freshman year in college, around the same time he began using marijuana and other harder drugs. At the beginning of his second semester, in early 2010, his son began having delusions and hearing voices telling him to act out violently. After threatening someone in his dorm, Smith’s son ended up in jail, then in a hospital, where doctors prescribed him anti-psychotic medication and released him a few days later.
Smith’s son moved home, seemed to be recovering and even got a part-time job during the summer following his cut-short freshman year. But then he stopped taking his medication and had a second mental break. Doctors did extensive testing and diagnosed him with schizoaffective disorder.
Smith said he’s learned a lot about the disease since then, and he believes that for his son drug use might have triggered what was an inevitable emergence of the underlying mental health condition, or the emergence of the condition might have spurred self-medication with drugs.
Two years later, Smith’s son tried again to enroll in college, but had another mental break. Since then he has gone through increasingly rapid cycles of mental breaks, hospitalization, medication, stabilization, then abstaining from his medication or using drugs again, leading to the mental breaks. Smith’s son, like many who are prescribed antipsychotic medication, would observe his symptoms go away, stop taking the medication, fueling the cycle.
Smith said he struggled to get his son proper treatment using his own private insurance. In his experience, psychiatrists who could take a schizoaffective patient in his insurance network said they didn’t have capacity for his son, but he suspects they also had no desire to take on such a complex case.
According to the most recent research on dual-diagnosis patients, Smith’s son should be able to get treatment for his schizoaffective disorder and for his drug use, without either precluding or interfering with the other.
Lauren Snyder, the policy director for Mental Health Colorado, said that, ideally, patients like Smith’s son would be able to see physicians specializing in both conditions in one location. Cross-training physicians for dual-diagnosis patients could be another way to improve access for them, she said.
Melissa Eddleman, the behavioral health and managed care supervisor for the state’s Medicaid program, said the huge expense that would have come from adding the same language for Medicaid reimbursements as applied to private insurers regulated by the state is because of the way Medicaid pays for service.
“The way our payment structure works, it would have to be different,” Eddleman said.
Medicaid uses two different systems for paying for medical service, Eddleman explained. Mental health care is paid upfront to regional contractors who estimate the total cost for serving their portion of the Medicaid population — called a capitated system. Physical health care, like treating a broken bone or the flu, is paid to providers on a one-by-one basis — called fee for service.
Applying the dual-diagnosis parity section of HB1269 to Medicaid patients would have meant moving some of what is categorized as a physical condition, such as Alzheimer’s, traumatic brain injury or dementia, into the capitated mental health system. Budget analysts estimated the change would have meant an increase of $68 million in costs overall.
Because the federal government partially funds states’ Medicaid programs, federal approval of proposed changes might have been necessary. Lawmakers and the advocates pushing for the mental health care parity bill agreed to leave Medicaid with language that allowed the status quo categorization and payment system. Requiring the tougher standard for Medicaid, they feared, could derail the entire bill.
The bill does require the state’s Medicaid program to report in June how it is performing when it comes to mental health parity and make proposals for how to augment the program where needed. Advocates say they’re eager to see what the Medicaid officials report, but worry there still could be gaps in coverage because of the structure and funding of the program.
After struggling to find mental health care from private providers, Smith inquired at the county-run facility, but was told that his son could only get treatment there if he enrolled in Medicaid. So Smith helped his son get off his private insurance and enroll in Medicaid.
“I’m not sure I’d make that same decision again,” Smith.
Smith said that for the first couple years on Medicaid, in 2014 and 2015, his son’s care improved. Smith said his son was able to see physicians quickly and that there were Medicaid-covered residential transition centers where his son could stay during mental breaks, which were happening with increasing frequency.
Smith said his son has increasingly encountered diminished capacity from the state’s Medicaid mental health providers. Now, in crisis, his son is taken to a general hospital, Smith said, where he is hurried out. When Smith has tried to seek involuntary, “short-term” commitments for inpatient mental health care, which can last up to 90 days, he said he has been advised to not mention his son’s dual-diagnosis drug use, and focus only on his schizoaffective disorder, because it could complicate or prevent getting him care.
Eddleman, from the state Medicaid office, acknowledged that there is a statewide shortage of mental health care coverage for the program, and that although there is residential mental health care capacity, there is not a residential substance abuse facility.
“We are working on that, hopefully to come in July. So we’re doing some capacity building,” she said. “We look forward to having less complication with that in the future.”
Mental health care advocates say the kind of disconnect between the care required for a patient like Smith’s son is precisely what the dual-diagnosis provisions aimed to remedy. If a substance abuse disorder prevents someone from getting mental health care treatment, then the dual-diagnosis patients can slip through the cracks.
When the state’s Medicaid program provides its report on parity in June, advocates say, problems that still need to be resolved will hopefully become apparent.
Smith’s son has continued to struggle with his schizoaffective disorder, with drug use and with stable housing. In 2019, Smith said, his son was hospitalized four times over a two-month period. He also became homeless in the summer of 2019. Smith said he and his wife visit their son as often as they can and try to make sure that he’s staying on his medication, which comes now in the form of a shot every few weeks instead of daily pills. That makes it somewhat easier to keep him on it, Smith said.
Lately, their son has been staying at a shelter.