Opinion | Lisa Gomez wants to make insurers pay for your mental health care

“I don’t know if it’s the mom in me or New Jersey,” says Lisa Gomez, “but I don’t want to hear, ‘It’s too hard.’ We can’t do that. “

Gomez needs that courage. Her job is to make sure health plans and insurance companies pay for the care Americans are entitled to. She is the Department of Labor’s Assistant Secretary for the Employee Benefit Security Administration (EBSA). It’s an odd title for what Gomez does: She’s a mental health activist.

Her team is responsible health plans that cover more than 130 million American workers, retirees and their families. If a plan violates the law requiring insurers to cover both mental health treatment and physical treatment — the Mental Health Parity and Addiction Equity Act — that’s Gomez’s problem.

After a July report showed many insurers were failing, the Biden administration proposed tougher regulations. EBSA works for health plan compliance.

It’s hard work. More than half of adults who seek treatment for mental health problems in the United States do not receive it. I asked Gomez how her team can help. Our conversation has been edited for clarity and length.

Kate Woodsom: How can EBSA help more people get mental health treatment?

Lisa Gomez: We want patients, families, providers and employers to understand: You have rights, and we’ve got your back. If people are trying to get treatment, a doctor’s exam, or prescriptions and something doesn’t seem right, don’t assume it’s always been difficult.

It’s free to call a benefits advisor at 1-866-444-EBSA.

The advisor will look into the issue and even contact the plan to find out what’s going on. We had a woman whose daughter was in a mental health crisis and needed to go into a facility, but her health plan said it wouldn’t pay. She knew she couldn’t discharge her daughter, so she continued to pay. She heard about EBSA on a podcast, called and we helped her pay the claims.

By connecting with us, people help others. If we don’t know the extent of the problem, we can’t fix it.

How do you get insurance companies to comply with the Parity Act?

The law wasn’t aggressively enforced until about two years ago, so as a starting point, the Department of Labor is trying to have a dialogue to resolve these issues.

Some things are easier to address, like unnecessary prior authorizations or the plan’s exclusion of mental health, which has been neglected for 20 years. There are more difficult parts, such as not having enough providers in the network. Then we ask, “If there weren’t enough cardiologists, would you act the same way?” What can you do and what can the government do?’

If we try to work with plans and they don’t get action, we point them out in that annual report to Congress. We can refer them to court, but we have no power to impose fines. There are efforts in Congress to put more teeth into these laws, because we can only go so far.

Some insurers are departure virtual mental health services offered during the pandemic, including for eating disorders and addictions. Is this legal?

If a plan offers a benefit that is not required, it can change it if it gives proper notice. But if they discontinue this virtual mental health care, do they still offer virtual or telehealth care for medical care? A patient or provider should call 1-866-444-EBSA and ask, “Is this allowed by law?”

What do employers who buy health plans need to know?

They can demand that insurers provide benefits in accordance with the law – and they can tell insurers that they are willing to take their business elsewhere.

EBSA can help employers ask the right questions. For example, employers can ask insurance companies to benchmark their mental and medical benefits and providers. Are the companies investigated by the Department of Labor? Do they encourage mental health providers to join their network? Do they review the rates they pay these providers? Do they allow employers and participants to nominate mental health providers to be in network, as they often do with medical and surgical providers?

Is a National Mental Health Care Movement Needed?

Illegal restraints require people with mental and substance use disorders to run faster, jump higher, and clear more obstacles to get the benefits they are entitled to. This is wrong and it has to stop.

I have experienced the pain of losing friends to suicide. I also know how people can manage many conditions and lead meaningful, fulfilling lives if they have access to the care they need. It shouldn’t be more difficult to get care for severe anxiety than for severe shoulder pain.

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