Health plans are denying crucial mental health care for children, and parents are struggling to find a solution. A new bill can help catch the families that are falling through the cracks in our mental health system.
One child, who we’ll call Monica, was in eighth grade in 2021 when her struggle with suicidal ideation, depression and substance abuse began, according to data from one of thousands of cases of health plan service denials reported to the California Department of Managed Health Care since 2001. We don’t know Monica’s actual name, because this information is withheld by the department for privacy reasons. What we do know is that Monica would go on to report a total of 16 suicide attempts, and exhibited destructive behaviors like stealing, compulsiveness, poor hygiene, and alcohol and substance use.
Monica’s parents hoped that sending their daughter to a residential treatment center would help. But when they applied, their health plan denied the treatment. The plan told Monica’s parents that the residential treatment program wasn’t “medically necessary,” a common denial justification that patients find hard to disprove because its definition has historically been so vague.
Monica’s parents appealed the denial, but the health plan rejected them. That left one option: contacting the California Department of Managed Health Care’s Independent Medical Review.
To conduct an independent medical review, an expert medical professional reviews a denied, changed or delayed consumer request for a medical service, a denied payment for emergency treatment or a refusal to cover an experimental or investigational treatment for a serious medical condition. If the review is decided in an enrollee’s favor, the health plan must authorize and cover the service or treatment requested.
The independent medical review process may have saved Monica’s life. It overturned her health plan’s denial and forced the plan to provide the coverage and care Monica desperately needed.
Monica’s story is representative of thousands of families that obtain relief through the independent medical review process every year. Nearly 70 percent of consumer appeals to the state resulted in the patient receiving the service or treatment they requested from their health plan, and over half of cases filed were for a “mental disorder” diagnosis.
Unfortunately, too many families like Monica’s must fight health plans to get mental health care for their children. The process to get care is often time-consuming, confusing and burdensome, and many families will never file for an independent review on their own.
That is why we are sponsoring Senate Bill 238. Under this bill, parents will no longer have to appeal health plan decisions through the arduous Department of Managed Health Care process. Instead, health plans would be responsible for justifying their denials, as they currently are for older adults in the Medicare system. SB 238 would also require that health plans denying children treatment for mental health or substance use be submitted automatically to the state for independent medical review .
Our young people need mental health care now more than ever. A growing number of youth in California experience mental illness and substance use disorders. But fewer than 10 percent of youth who report needing substance use treatment services receive them, and suicide attempts among girls are rising. It is unconscionable that children are unable to access lifesaving care. SB 238 makes it easier for California’s children and youth to access lifesaving mental health care at a time they desperately need it. Let’s get this done for them.
Senator Scott Wiener represents San Francisco in the California Senate.
Lishaun Francis is a senior director at Children Now where she advocates for the best state policies to support the mental health of California’s children and youth.