Community Health & Wellness

Rep. Tarra Simmons says she was denied mental health treatment, or had it cut off prematurely, at many points during her recovery from post-traumatic stress disorder. Absent mental health treatment, she coped with drugs.

“That’s how I ended up in prison,” Simmons, Washington’s first formerly incarcerated lawmaker, said before the House Health Care & Wellness Committee in January. “If we want to get real about crime and addiction, we have to treat mental health. Because that’s the only real root cause of a lot of these problems that we face.”

Simmons, D-Bremerton, says too many Washingtonians are not receiving preventative behavioral health care because commercial insurance companies deem that care not to be “medically necessary.” 

Her new policy, House Bill 1432, could fix that. The Senate approved the far-reaching legislation on Monday and it now heads to Gov. Bob Ferguson’s desk.

State Rep. Tarra Simmons, D-Bremerton

‘Medically necessary’

The bill requires private insurance companies to follow transparent and widely agreed-upon criteria when making coverage determinations about mental health and substance abuse treatments. Carriers would have to cover services a patient’s doctor deem “medically necessary.” 

In a phone interview, Simmons said most crimes are the result of untreated mental health conditions. Providing timely and affordable access to behavioral health care is critical to keeping people struggling with their mental health from spiraling to the point of crisis or jail.

“This is to get us out of just working on re-entry from incarceration,” she said, “and try to prevent crime instead.” 

Supporters of Simmon’s bill say it would better align commercial insurance plans with Medicaid, the state-federal insurance program for those with low incomes or disabilities. Medicaid is far from perfect, experts agree. But government insurance programs often provide better coverage of mental health care than commercial ones. 

“In many ways, people who have public health insurance — who have Medicaid — have better access and more comprehensive access (to mental health care) than people on very nice private insurance programs,” said Jürgen Unützer, an adjunct professor who chairs the University of Washington Department of Psychiatry and Behavioral Sciences, while testifying in support of the legislation. 

Refusing mental health care can be more expensive in the long run

Insurance plans typically offer coverage of some services only in the event that they are “medically necessary.” Generally this applies to services that can cure or mitigate a patient’s condition where there is not a reasonable alternative.

Private insurance companies often use their own definition — typically purchasing them from third-party companies — which can be out of line with a patient’s physician or medical best practices.

Brian Allender, chief medical officer for the Behavioral Health and Recovery Division of the King County Department of Community and Human Services, wrote in a letter supporting House Bill 1432, that refusing to cover mental health treatment leads to delayed care and repeated use of crisis services and hospitalizations.

Individuals are prone to cycle through hospitals and struggle with symptoms that impact their functioning and overall recovery, he wrote. In King County, clinicians often advise families to take children with serious mental health issues off their private insurance plans and sign them up for Medicaid so that they can obtain care “recognized as a base standard for decades.”

“When private insurers inappropriately deny treatment and tell a patient that the level of care their doctor prescribed is not medically necessary, the delay in care can mean the difference between long-term improvement and ending up in and out of state-funded services for years to come,” Allender said. 

Evidence-based criteria

Supporters of Simmons’ bill say it closes a loophole allowing insurance companies to deny critical mental health care, often in advancement of financial or business goals. Insurance companies would be required to use the same transparent, evidence-based criteria as medical doctors.

David Lloyd, chief policy officer at Inseparable, a national nonprofit that works to expand access to mental health care, said the bill is fundamentally about making sure people can get care they need and protecting taxpayers. The bill, which Inseparable brought to the Legislature, helps prevent insurers from shifting costs for care on to Medicaid or other publicly supported social service programs, Lloyd said.

“The problem is that many people think they have health insurance coverage for mental health – and in fact have been paying for mental coverage – and when they need services that are being recommended by their doctor, their insurance company too often says that it’s not medically necessary,” he said. “It’s really important that commercial insurance also be playing their part so that we’re not shifting costs onto public programs.