When a patient at St. James Health Center needs mental health care, the first thing Susana Farina does is check insurance.
The type of insurance patients have — if they have any at all — determines what kind of doctor they can see and even the date of their appointments. The Affordable Care Act covers treatment for some mental health disorders, such as depression and anxiety, but the law is not comprehensive and many Californians with mental illnesses still face challenges accessing care.
As a result, whether patients are uninsured, have private coverage or government benefits determines their access to services.
“What their insurance is drives treatment,” said Farina, behavior-health coordinator and licensed psychologist with Gardner Family Health Network, which includes St. James. The network serves 55,000 primarily low-income and uninsured patients in Santa Clara County. St. James Health Center, one of the biggest in the group, sits near downtown San Jose.
To try to get patients the treatment they need, doctors at St. James are beginning a team approach to mental health — one that incorporates primary-care providers, in-house behavioral health workers and a referral system to therapists and psychologists around Santa Clara County.
The Affordable Care Act and California’s Mental Health Parity Act, which the Legislature updated this year, have spurred the changes to mental health care at St. James and other clinics statewide.
The federal health law requires the vast majority of residents to buy health insurance. Those who don’t can face tax penalties.
The state parity law requires health insurance providers to pay for the treatment of some mental health diagnoses, above and beyond those required under the federal law. While the state law previously focused on serious diagnoses that required hospitalization, the list has expanded to cover more common or less severe diagnoses, like depression, eating disorders and schizophrenia.
As a result, mental health providers are preparing for a surge of patients as the newly insured seek help for various conditions that are now covered.
But there are obstacles.
Not all behavioral therapists take all insurance plans. Some don’t take any at all. A number of therapists say they can make more from patients who pay out of pocket than from getting reimbursed by insurance companies. Others take private insurance but don’t accept Medi-Cal, the state’s insurance program for low-income residents. And still others only take Medi-Cal patients.
Figuring out which providers take which kinds of insurance can get tricky, Farina said. Her department often refers out patients who need treatment above what St. James offers.* She doesn’t want to send those patients to providers who will turn them away because of their insurance, or lack thereof.
And then there are patients who remain without insurance, she said. Often these patients are low-income, undocumented residents who don’t qualify for Medi-Cal or the Affordable Care Act.
While St. James won’t turn those patients away, they might have to wait a few weeks longer for an appointment so the clinic can recoup its costs by first seeing patients with coverage, Farina said.
The uninsured may also become part of a health-care juggling act.
For some patients, Farina said, mental health treatment has become a complicated shuffle between a primary-care provider and a psychologist who takes insurance and provides drugs. The primary-care doctor, who accepts the patient’s insurance, has to step in to provide talk therapy in place of a counselor or therapist.
Further complicating access to treatment is the fact that insurance companies are not required to cover treatment for all mental health disorders. Anxiety and depression are on the list, but Post Traumatic Stress Disorder and some eating disorders are not.
But efforts are underway to make the process easier.
The California Department of Health Care Services is working on agreements regarding payments, referrals and screening tools that should provide direction for both providers and insurers, said spokeswoman Carol Sloan. These agreements, which should be finalized by June 30, will apply to patients with Medi-Cal or other government-funded plans for low-income patients.
Sloan called the state’s expanded mental health parity law “a much-needed bridge for the gap in coverage that existed before.”
The state also announced Thursday that it will distribute $75.3 million in grants to 28 counties to help residents with severe mental illness. The goal is to prevent those who need treatment from landing in jail or the hospital repeatedly.
At St. James, behavioral health clinicians have started working with primary-care providers to identify patients suffering from anxiety or depression.
Patients are beginning to get treatment under the new insurance rules, but the process has involved a learning curve for both behavioral health and medical providers on how to detect symptoms.
A patient could say, “‘Oh, I have headaches,’ but really they’re depressed,” Farina said. Or, someone not following doctors’ orders for managing diabetes or another disease could actually be suffering from depression.
Each patient is screened for depression at every visit, Farina said. If a doctor finds symptoms, someone from behavioral health is summoned to meet the patient right then. Those providers then start navigating the maze of insurance to figure out the best care.
Still, for Jamie Gamboa of San Jose, finding a mental health provider to help one of his daughters has not been easy.
Gamboa, 49, is the father of 19-year-old twin girls. He supports the Affordable Care Act, in theory: “The idea is good. The idea is very good,” he said.
But in practice, Gamboa is frustrated. He signed his daughters up for insurance this year through the state’s exchange, Covered California. But Gamboa has experienced confusing delays in getting his daughter who needs mental health treatment the help she needs.
For the time being, Gamboa is taking her to St. James for appointments with a behavioral health clinician. He pays $40 per visit — an amount he said he can afford for now.
*Note. This story was edited on May 1 to clarify that St. James refers out patients who need care above and beyond what the clinic can provide.