His team holds 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 mental health treatment as much as physical treatment (the Mental Health Parity and Substance Abuse Equity Act), that’s Gomez’s problem.
After a July report showed many insurers were falling short, the Biden administration proposed tougher regulations. The EBSA works to bring health care plans into compliance.
This is a difficult work. In the United States, more than half of adults who seek treatment for mental health problems do not receive it. I asked Gomez how her team could help. Our conversation has been edited for clarity and length.
Kate Woodsome: 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 support you. If people are trying to get treatment, a doctor’s appointment, or covered prescriptions, and something doesn’t seem right, don’t accept that it was always difficult.
It’s free to call a benefits advisor at 1-866-444-EBSA.
The advisor will look into the problem and even contact the plan to find out what’s going on. We had a woman whose daughter was suffering a mental health crisis and needed to be placed in a facility, but the health plan told her she wouldn’t pay. She knew she couldn’t fire her daughter, so she continued to pay. She heard about EBSA on a podcast, called, and we helped her get her claims paid.
By contacting us, people help others. If we don’t know the scale of the problem, we can’t solve it.
How do you get insurance companies to comply with the parity law?
The law was only aggressively enforced about two years ago, so as a starting point the Department of Labor is trying to start a dialogue to resolve these issues.
Some things are easier to fix, like unnecessary pre-authorizations or a mental health exclusion from the plan that has been neglected for 20 years. There are more difficult elements, like not having enough providers on the network. We then ask ourselves: if you didn’t have enough cardiologists, would you do the same thing? What can you do and what can the government do?
If we try to work with plans and they don’t act, we name them in this annual report to Congress. We can take them to court, but we don’t have the power to impose fines. There are efforts in Congress to give these laws more teeth, because we can only go so far.
Some insurers are liquidation virtual mental health services offered during the pandemic, including for eating disorders and addictions. Is this legal?
If a plan offers a benefit that they are not required to provide, they can change if they give proper notice. But if they end these virtual mental health benefits, do they continue to offer virtual or telehealth benefits for medical care? A patient or provider should contact 1-866-444-EBSA and ask: Is this allowed by law?
What should employers know when purchasing health plans?
They can demand that insurers provide benefits in accordance with the law and tell insurers that they are prepared to expand their business elsewhere.
The EBSA can help employers ask the right questions. For example, employers can ask insurance companies for a comparative analysis of their mental health and medical benefits and providers. Have the companies been investigated by the Department of Labor? Do they encourage mental health providers to join their network? Are they reviewing the rates they pay to these suppliers? Do they allow employers and participants to designate mental health providers who should be in-network, as they often do with medical and surgical providers?
Is a national movement for mental health care needed?
Illegal limitations force people with mental health and substance use disorders to run faster, jump higher, and jump through more obstacles to get the benefits they are entitled to. This is wrong and it must stop.
I felt the pain of losing friends to suicide. I also know how people can manage many conditions and live meaningful, fulfilling lives if they can access the care they need. It should not be more difficult to get care for severe anxiety than for severe shoulder pain.
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