At a time when much is said about a need for increased access to behavioral health care, legislative reforms are a challenge. Some who have attempted to reform Medicaid and Medicare have included Congressman Chris Gibson at a federal level and Assemblywoman Aileen Gunther, who chairs the Assembly Mental Health Committee in Albany. But the problem is not resolved.

A major inequity in the current health insurance system is the fact if a person is on Social Security, mental health and substance abuse counseling are most likely designated as “carved-out benefits” of managed care. This means they are not covered by such plans as Hudson Health Plan, Fidelis Care NY that provide managed-care Medicaid to the public, i.e. those who are not classified as disabled or otherwise covered by Medicare.

If a person has Supplemental Security Income or Social Security Disability Insurance (SSI or SSD), or is a senior citizen collecting a pension, they are most likely limited to seeking mental health or addiction counseling from a Medicare provider, which can be especially hard to find in a rural county like Sullivan. A relatively rare exception to the carve-out rule applies to those eligible to be in a nursing home (even if they are not) with Medicaid Managed Long-Term Care. Most SSI/SSD recipients in the community do not meet “long-term care” criteria.

This long-standing inequity is neither a result of, nor is it resolved by, the controversial Affordable Care Act (ACA), also known as Obamacare. It has resulted in larger numbers of people with insurance, but those with Medicare are still relegated to a limited pool of mental health practitioners.

A real-life example is a woman referred by her gynecologist for mental health counseling due to depression and anxiety after undergoing a total hysterectomy for cervical cancer. She responded well, both to her cancer treatment and to psychotherapy. She was making progress with managing her moods and panic attacks, but suddenly had to stop her attending counseling when her application for Social Security Disability application was approved, and outpatient behavioral health became a “carved-out” benefit. Even if she was seeing a participating provider in her managed care network, only a Medicare provider was eligible for reimbursement under her policy once her SSD benefits for the cancer began. Due to her income, she was not able to afford even a reduced self-payment. She continued antidepressant medication prescribed by her doctor (which was still covered by her insurance), but she was not interested in switching therapists to a county or state operated clinic that could bill her “straight” Medicaid. This gap in coverage is something that occurs too often.

As a psychotherapist, I get calls every week from people with managed-care Medicaid asking for appointments for mental health treatment. If they have a Medicaid plan I participate with, the next question I have to ask is whether they receive Social Security benefits. Most say “no,” and they are offered appointments. If the answer is “yes,” regardless of the severity of the condition for which they are seeking treatment, they are advised to call the number on the back of their insurance card and request a referral to someone who is in-network New York State Medicaid or Medicare.

Gibson and the others on both sides of the aisle have initiated efforts to reform Medicare by allowing broadening of the pool of qualified treatment providers. This approach is good for the free market system and good for consumers.

In New York State, the Medicaid Institute at United Hospital issued a report in 2012: “Implementing Behavioral Health Care Reform in New York’s Medicaid Program.” The authors explain, “This report examines the implementation of Medicaid policy changes in New York, which will require participation in care management for beneficiaries receiving behavioral health services. Until now beneficiaries have typically received these services under a fee-for-service [i.e.straight Medicaid] payment model.”

When this inequity will be remedied locally is anyone’s guess. Provider Relations departments at insurers that manage health care benefits for Sullivan County recipients of Medicaid tell me they have no information about these “carve-outs” being eliminated any time soon. Readers may wish to contact their NYS Senate, Assembly, and U.S. Congressional representatives to advocate for reform.

[Tom Rue is a Licensed Mental Health Counselor in New York, certified as a clinical mental health counselor by the National Board of Certified Counselors. Contact 845/513-5002 or www.choicesmhc.com.]