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State Ombudsmen Help Families Secure Care and Assert Parity Rights

State departments of insurance and Medicaid agencies too often do little to help people find the mental health and addiction treatment they need or to investigate insurers and Medicaid managed care organizations (MCOs) when they deny care. Rather, individuals and their families are frequently left to fend for themselves, with little help from the regulators tasked with protecting them.

Thankfully, policymakers are starting to recognize that we cannot continue to place such a heavy burden on families, often in the middle of a crisis. An increasing number of states have set up “ombudsmen” to help people find care, navigate complicated government systems, and file insurance appeals and complaints. Traditionally, an ombudsman is a public official appointed to serve as a neutral, impartial, and independent investigator of residents’ complaints regarding potential violations of rights and, when appropriate, assist in remediations.

Some of the new mental health and addiction ombuds offices are also specifically directed to help identify potential violations of state and federal parity laws and to assist with complaints until they are resolved.

Two states that have recently created mental health and addiction ombuds offices are Texas (HB 10 in 2017) and Colorado (HB 18-1357 in 2018). Key responsibilities for these offices include assisting individuals, regardless of insured status or type of insurance, and treatment providers with concerns or complaints regarding mental health and substance use disorder care accessibility. Additionally, legislation in both states requires the offices to:

  • Identify and track potential violations of state and federal parity laws;
  • Receive and report concerns and complaints relating to inappropriate care or mental health commitment;
  • Provide appropriate information to help consumers obtain behavioral health care;
  • Develop appropriate points of contact for referrals to other state and federal agencies; and
  • Provide appropriate information to help consumers or providers file appeals or complaints with the appropriate entities, including insurers and other state and federal agencies.

The Texas ombudsman is also required to participate in the state parity workgroup established by HB 10 and to deliver summaries of the concerns, complaints, and violations that have passed through the office. The Colorado ombudsman must produce a similar report, and include documentation of actions taken. This must be posted annually to a public website and submitted to a variety of other state officials, offices, and legislative committees.

New York recently authorized a similar Office of the Ombudsman for Substance Use Disorders and Mental Health Conditions in its 2018 budget bill (S7507/A9507C). The legislation, signed into law in April, requires the office to “ensure that [New Yorkers] receive appropriate health insurance coverage” by investigating and helping to resolve concerns and complaints made by both consumers and treatment providers.

Texas, Colorado, and New York join other states, including California and Minnesota, with existing offices of ombudsman for mental health and substance use disorders. Minnesota established the Ombudsman for Mental Health and Developmental Disabilities in 1987 in order to “promote the highest attainable standards” for individuals receiving care for mental health and addiction. California’s Mental Health Office of the Ombudsman is combined with the Ombudsman for Medi-Cal Managed Care and serves Medi-Cal (California’s Medicaid program) members. Among other responsibilities, the Ombudsman helps members access mental health services and resolve issues with Medicaid MCOs.

We are encouraged by the Texas, Colorado, and New York mental health and addiction ombuds offices, particularly because of the emphasis they place on identifying and tracking parity violations. We are hopeful that, as these programs continue, more individuals will be able to access lifesaving treatment in a timely manner and assert their right to coverage.

To learn more about parity rights and how to take action against insurance denials of mental health and addiction treatment services, visit www.dontdenyme.org.

 

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“We stand on the doorstep to make momentous progress in advancing the cause of this new civil rights struggle started by the work of President Kennedy over 50 years ago.”
— Patrick J. Kennedy
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