The reality in the United States is that very few people can afford to pay for their medical care directly. Most people prefer to access care through health insurance. However, navigating health care insurance and its limitations can be incredibly challenging, even for medical professionals who navigate these types of issues on a daily basis.
When developing discharge plans, hospital care teams typically attempt to take a person's insurance coverage and challenges into account.
This will lead to several points that your team will likely review with you:
Do you currently have health insurance? If not, would you like assistance signing up for government subsidized care?
Frequently hospitals can help you with submitting paperwork to become enrolled in state or federal care plans. However, the hospital team typically has no control over whether you are ultimately deemed eligible or how quickly this paperwork is processed. Despite this, if a person is uninsured, it is helpful overall to at least start this paperwork as it will mean more outpatient care options in the future. Additionally, patients who appear to meet the criteria for government subsidized healthcare may be eligible for other free or low cost care options in the area.
Are there challenges to accessing mental health care coverage under your current insurance plan?
For background, The Mental Health Parity Act of 1996 (MHPA) mandated that large group health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical or surgical benefits.
Due to numerous loopholes in the MHPA, The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) was created. This federal law prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical or surgical benefits.
In other words, at first glance these two laws would mean that a person shouldn't have more difficulty accessing mental health care than they do accessing any other kind of medical care. However, several groups can apply to be exempt from the MHPAEA:
Small employer (less than 50 people) group health plans
Self-funded group health plans
Businesses that can provide actuarially certified documentation that adding mental health parity to their plans would lead to a 2% increase in the cost of coverage the first year, or an increase of 1% the following year. These businesses can apply for a one year exemption.
As a result, determining whether a patient's insurance will cover a potential mental health care treatment can become quite complicated.
Additionally, even when insurance is accepted, the patient themselves may have additional limitations to using their healthcare plan. For example, if a person has a large out of pocket deductible that needs to be met annually, they may be hesitant to move forward with the inpatient team's first proposed plan, and they might want to learn about other more cost-effective alternatives.
Daily rounds and appointments with your inpatient care team will typically include updates on what the team has been able to find out in terms of insurance limitations. Ideally, this information will lead to conversations about what will make an acceptable treatment plan moving forward.
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