Her team holds accountable the 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 treatments as much as physical treatments — the Mental Health Parity and Addiction Equity Act — it is Gomez’s problem.
After a July report showed many insurers falling short, the Biden administration proposed stronger regulations. EBSA is working to get health-care plans to comply.
It is a tough job. More than half of adults who seek treatment for mental health issues 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 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 have your back. If people are trying to get treatment, a doctor’s appointment or prescriptions covered, and something doesn’t seem right, don’t accept that it’s always been hard.
It’s free to call a benefits adviser at 1-866-444-EBSA.
The adviser will walk through the problem and even contact the plan to find out what’s going on. We had one woman whose daughter was in a mental health crisis and needed to get into a facility, but the health plan told her they wouldn’t pay. She knew she couldn’t discharge her daughter, so she kept paying. She heard about EBSA on a podcast, called, and we helped her get the claims paid.
By contacting us, people are helping others. If we don’t know the scale of the problem, we can’t fix it.
How are you making insurance companies comply with the Parity Act?
The law was not 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 pre-authorizations or a mental health exclusion in the plan that’s been overlooked for 20 years. There are more difficult pieces, like not having enough providers in network. Then we ask, “If you didn’t have enough cardiologists, would you be acting the same way? What can you do, and what can the government do?”
If we’re trying to work with plans and they’re not taking action, we name them in this annual report to Congress. We can refer them for litigation, but we don’t have the authority 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 winding down virtual mental health services offered during the pandemic, including for eating disorders and addictions. Is this legal?
If a plan is offering a benefit they’re not required to, they can change if they give appropriate notice. But if they’re discontinuing this virtual mental health benefit, are they continuing to offer virtual or telehealth benefits for medical care? A patient or provider should contact 1-866-444-EBSA and ask, “Is this allowed under the law?”
What do employers buying health plans need to know?
They can demand that insurers provide benefits in compliance with the law — and they can tell insurers they’re willing to take their business elsewhere.
EBSA can support employers to ask the right questions. For instance, employers can ask insurance companies for a comparative analysis of their mental and medical health benefits and providers. Have the companies been investigated by the Department of Labor? Are they encouraging mental health providers to join their network? Are they reviewing the rates they pay those providers? Do they allow employers and participants to nominate mental health providers that should be in network as they often do with medical and surgical providers?
Is a national movement for mental health care necessary?
Unlawful limitations require people with mental health and substance use disorders to run faster, jump higher and clear more hurdles to get the benefits they’re entitled to. That’s wrong, and it has to stop.
I’ve experienced the pain of losing friends to suicide. I also know how people can manage many conditions and lead meaningful, fulfilling lives if they can access the care they need. It shouldn’t be harder to get care for severe anxiety than for severe shoulder pain.
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