NADD U.S. Policy Update (from the NADD Bulletin Volume VII Number 6)

Complete listing

Limitations in Third Party Reimbursement and the effects on Mental Health Services for Individuals with Intellectual Disability

Anne D. Hurley, Ph.D. Tufts University School of Medicine

In the United States, the majority of outpatient and inpatient mental health treatment is funded either by public or private insurance programs. The government does not provide a national health care program, and approximately 45 million people do not have any health insurance at all, resulting in a national health care crisis. For people with disabilities that prevent them from working, health insurance is frequently provided through either the Medicare program or Medicaid program, and the majority of individuals with intellectual disability have one or both of these health insurances. This column reviews current issues and trends in insurance coverage and the provision of mental health care for individuals with intellectual disability.

Health Insurance Options for People with Intellectual Disability

Medicare is a federal program for people who are retired or disabled and who cannot work, and who have worked a required amount of time vesting in Social Security, Federal Government, or Railroad retirement plans. Through a special benefit, a permanently disabled child with a disability occurring before age 22(such as intellectual disability) can receive Medicare if the parents are deceased, disabled, or retired and receiving Medicare. Thus, the majority of adults with intellectual disability will eventually receive Medicare insurance.

Medicaid is also a federal program that is available to those who cannot work due to disability and are living in poverty, and to other groups such as women with children with little or no income. Thus, entitlement to Medicaid is associated with poverty programs and is very politically sensitive. Medicaid is a federal program given to states, and each state government has latitude to set many parameters in their administration of the Medicaid program.

A small but growing percentage of those with intellectual disability will have private health insurance through an employer, or their parent's employer.

Many adults with intellectual disability have multiple insurance coverage. For example, it is possible to have Blue Cross/Blue Shield, Medicare, and Medicaid at the same time. In this case, the BC/BS policy determines mental health benefits and the other insurance plans serve as back up for copays and deductibles.

Mental Health Outpatient and Inpatient Reimbursement

There are several basic strategies used to limit mental health reimbursement from insurance companies. The first is to require that the patient pay higher copay for a psychiatric visit compared to a medical visit. The second is to limit the number of visits per years. Third, the insurance company may require elaborate treatment plans that must be approved by the insurer. Lastly, the health insurance company may limit the choice of provider by authorizing only clinicians in their "network." Only certain providers are accepted into the "network," and providers are asked to sign a contract, and possibly reapply annually. Providers must accept the conditions of the contract and payment offered by insurers.

Medicare sets the standard for medical care in the U.S. It defines procedures (such as defining what constitutes an individual psychotherapy session). Medicare treats mental health disorders differently than any other medical conditions. For example, for a psychotherapy visit, the patient must pay a 50 % co-pay. This is not the case for other forms of medical care.

Medicare outpatient psychiatric visits are also different that any other medical specialty. For outpatient psychiatric care, Medicare has special psychotherapeutic care codes, and these are the codes used by all health insurance companies. Under Medicare, a psychiatrist bills an outpatient psychopharmacology appointment as a 15-minute visit, no matter how complex the patient is or how long the visit lasts. As a result, the 15-minute psychopharm visit has become the industry standard and it is not sufficient for the complex patient.

Medicaid has a primary goal of cost containment in most states. Nationally, the Medicaid budget is viewed by policy makers as spiraling out of control. In response to the need to contain costs, a number of strategies are being implemented to decrease Medicaid eligibility and contain reimbursement for the provision of health care. In addition, psychiatric services are typically treated differently from other illness categories. In many states, mental health services are "carved out" of the Medicaid program and managed by an intermediary company, typically a for- profit company with an arrangement to keep some profit if the cost of overall Medicaid expenditures can be reduced.

The "intermediary" company sets policies and provides tight management of mental health services through a variety of mechanisms, with mixed results. In Massachusetts, for example, most Medicaid enrollees without additional insurance have their mental health benefits managed by the private company, the Massachusetts Behavioral Health Partnership (MBHP). MBHP has a generous program for outpatient psychotherapy and psychiatric visits in terms of number of visits per quarter, but they pay a low amount per visit. As is typical for Medicaid-contracted providers, the length of stay in a hospital is closely monitored and a typical length of stay may be 4 to 7 days. MBHP has a network of emergency service contracts for community screening teams and only designated hospital emergency rooms are an authorized destination.

MBHP enacted a code allowing a bit more time when treating a complex patient. Thus, in addition to a 15-minute psychopharm visit, psychiatric clinicians may bill a 20-minute visit for complex patients with a bit more payment. In addition, MBHP provides an enhanced rate of reimbursement for a specialty inpatient program for people with intellectual disability at the University of Massachusetts Medical Center. It is important to note, however, that Medicare does not pay the same enhanced rates in Massachusetts for the same services and does not allow for increased payment for complex patients.

Employer provided health insurance companies use the same strategies as Medicare and Medicaid. Most Health Maintenance Organizations (HMO) plans restrict the number of providers, require prior approval of treatment plans, and limit number of visits. For private insurers, a growing number of employers are using health maintenance organizations, or have carved-out their mental health services to another company. For example, many Blue Cross/Blue Shied HMO plans in Massachusetts carve their mental health benefits out to Magellan Behavioral Health. Magellan limits the providers who may be seen by an individual. Depending on the company plan, copays are higher for mental health care.

Insurance companies also generally reject "multiple providers." For example, I have been unsuccessful in arguing that a woman with major mental illness needs "multiple providers." She has a psychiatrist for medication, psychologist for individual therapy, group therapy to learn sexual abuse prevention skills, and case consultation from a behavioral therapist working with her psychiatrist, day and residential providers in the community.

Cost saving strategies that limit treatment options may have contributed to what is now a shortage of qualified mental health providers and effective mental health services. Even if insured, many individuals are finding it increasingly difficult to find a mental health provider in a timely fashion, and many cannot bear the burden of higher copays for visits. Many patients need more intensive visits than are authorized. Testimony by the American Association for Geriatric Psychiatry on the need for a mental health parity, or equivalency to medical illness, bill in July 2001, summed up the situation:

"We believe that arbitrary limits on coverage of mental health care should be eliminated wherever they exist. Today nearly 98 percent of all private health benefit plans impose arbitrary limits on coverage of mental health services ----- requiring patients to pay higher coinsurance, allowing fewer visits to the doctor or shorter stays in hospital and applying higher deductibles before benefit payments begin. These limits, which have been in place since the early days of health insurance, are based on the assumption that mental health problems are somehow less real, or less amenable to treatment, than other health problems."

For people with intellectual disability, the structure of mental health "procedures" can result in poor services. A 15 minute visit, or even 20 minute visit, is not adequate for the majority of patients to assess their mental status, collect information from caregivers, explore other medical conditions and medications that are relevant, and discuss the treatment plan with the patient and caregivers. Limitations on providers cause a distinct burden for the intellectual disability population. There are few mental health specialists with training and experience with this population. They may not, however, be on specific health insurance company panels. For example, the parents of one young adult who has been in a serious mental health crisis for several years approached me for evaluation and treatment of their child. I was not on the panel of that insurance company. The mother went through appeals to see me, first documenting the number of providers she had called who either had no experience with intellectual disability, or who had closed practices. Two months later, I received a phone call authorizing my treatment, asking me to reply. I returned the call that day, and three months later, after many calls, I have yet to receive a call back to discuss the contract as asked. This week, I received a contract in the mail to sign, but it did not include the terms of payment.

Furthermore, for people with intellectual disability, it is essential that mental health services include collaboration with the system in which the person receives support. In Massachusetts, there is a Medicaid approved "case conference" code. MBHP limits this code, however, to being used only once every 16 weeks. For people with intellectually disability, and major mental illness or severe behavioral disturbance, this code should be allowed to be used as often as necessary to support the person in the community.

Mental Health Parity

In order to equalize treatment of mental illness with other medical illness, a movement to provide mental health parity began over a decade ago. The Mental Health Parity Act of 1996 (MHPA) is a federal law that prevents group health plans from placing annual or lifetime dollar limits on mental health benefits that are lower than those for medical and surgical benefits. This law was a first step, for although it required "parity" with regard to dollar limits, it did not require group health plans and their insurers to include mental health coverage in their benefits package. It also applied only to group health plan of employers for companies over 50 individuals. This law did not prevent increasing co-payments or limits on number of visits for mental health benefits, for example. It did not apply to Medicare and Medicaid and some states have their own parity laws as well. Further, in May of 2000, the General Accounting Office (GAO) of the Federal government reported that while most employers complied with the act, 87% of those restricted their mental health coverage in other ways, substituting new barriers for those ruled out under the law.

In March 2001, The Mental Health Equitable Treatment Act was introduced by Senators Demenici and Wellstone. This bill has labored in the house and senate with many debates, and at this time the bill is still under consideration and will be up again in the house and senate. Advocates have rallied families, patients, and the community at large to lobby their senators and congressman to act on this law. Since the tragic death of Paul Wellstone, this bill has become known as the "Wellstone" act.

Like the 1996 bill, the current bill only applies to group employer plans. In it, group health plans would not be allowed to set different treatment limits or financial requirements in the areas of copays, deductibles, length of hospital stay, or number of outpatient visits. However, it will not stop the management of mental health benefits, and may still require an "authorized treatment plan." It will also not require plans to provide coverage for benefits related to alcohol and drug abuse. If passed, it will still not affect Medicare or Medicaid.

At this time, advocates are hopeful that it may come to the floor again and be passed this year. Anyone with any interest in mental health care should contact their senator and congressman about this bill, and the web sites below can help in this action.


Due to escalating costs of health care in the United States, and lack of a national health care program, many ways to reducing costs are being enacted by the public sector and employers health care plans. Mental health benefits have been particularly singled out for reductions in treatment. These changes are impacting all citizens, and those with intellectual disability are being particularly restricted because their care largely comes under individual state budgets that serve the poor, and can be highly politicized. Advocates, families, and professionals must work in concert with the state government and the insurance industry to maintain a basic support service network for people with intellectual disability and mental health needs.


1. American Association for Geriatric Psychiatry (AAGP) .

2. Centers for Medicare & Medicaid Services (DMS)

3. Mental Health Parity Update


4. National Mental Health Association


5. Sovner, R., Beasley, J., & Hurley,A.D. (1995). How long should a psychiatric inpatient stay be for a person with developmental disabilities? The Habilitative Mental Healthcare Newsletter, 14, 1-8.