Christopher Capozziello for The New York Times
Cathy Morelli, right, with her daughter Melissa. Their insurer ultimately was forced to pay for the mental health care for Melissa that it initially denied.
THE first time Melissa Morelli was taken to the hospital, she was suicidal and cutting herself, her mother says. She was just 13, and she had been transferred to a psychiatric hospital, where she stayed for more than a week. Her doctors told her mother, Cathy Morelli, that it was not safe for Melissa to go home. But the family's health insurance carrier would not continue to pay for her to remain in the hospital.
The second time, the same thing happened. And the third and the fourth. Over the course of five months, Ms. Morelli took Melissa to the hospital roughly a dozen times, and each time the insurance company, Anthem Blue Cross, refused to pay for hospital care. "It was just a revolving door," Ms. Morelli said.
"You had not been getting better in a significant way," Anthem explained in one letter sent directly to Melissa, then 14, in July 2012. "It does not seem likely that doing the same thing will help you get better."
Desperate to get help for her daughter, Ms. Morelli sought the assistance of Connecticut state officials and an outside reviewer. She eventually won all her appeals, and Anthem was forced to pay for the care it initially denied. All told, Melissa spent nearly 10 months in a hospital; she is now at home. Anthem, which would not comment on Melissa's case, says its coverage decisions are based on medical evidence.
Melissa's treatment did not come cheap: it ultimately cost hundreds of thousands of dollars, Ms. Morelli said. Patients often find themselves at odds with health insurers, but the battles are perhaps nowhere so heated as with the treatment of serious mental illness.
It was not supposed to be this way. A federal law, the Mental Health Parity and Addiction Equity Act of 2008, was aimed at avoiding fights like this over coverage by making sure insurers would cover mental illnesses just as they cover treatment for diseases like cancer or multiple sclerosis.
Long a priority of Senator Edward M. Kennedy of Massachusetts, it was squeezed into a bank bailout bill with the help of Christopher J. Dodd, then a Democratic senator from Connecticut, after Mr. Kennedy learned that he had brain cancer, which turned out to be fatal. The law requires larger employer-based insurance plans to cover psychiatric illnesses and substance-abuse disorders in the same way they do other illnesses.
But five years after President George W. Bush signed the law, there is widespread agreement that it has fallen short of its goal of creating parity for mental health coverage.
As enrollment in coverage under the Affordable Care Act becomes available on Tuesday, the rules underlying mental health coverage in general — for both private insurers and the new health care exchanges — are still unclear, mental-health patient advocates say, leaving patients and families to grind through the process as best they can.
DECIDING how mental illness should be treated — and at what cost — is no easy matter. Unlike some physical ailments for which there are reams of studies suggesting a relatively clear standard of care, there is often little accepted medical evidence to support the range of treatments for many mental illnesses, like schizophrenia and severe depression.
"It's very different from the approach to a bypass procedure or a hip replacement," said Karen Ignagni, the C.E.O. of America's Health Insurance Plans, a trade association representing the nation's health insurers.
At issue is not coverage for run-of-the-mill care like prescription medications for depression or a few visits with a therapist. Insurers generally cover these costs the same way they cover medications for, say, high blood pressure.
But when patients need months of residential care, for example, or meetings with a therapist several times a week, insurers balk. The insurance executives say that the medical benefits of such treatments are not clear and that the industry is essentially being asked to write a blank check.
Mental health accounts for a small part of total health care spending — by one estimate, $113 billion annually, or less than 6 percent of the $2.6 trillion overall health care bill. But pressure is intensifying on insurers under the Affordable Care Act, which includes mental heath care as an essential benefit, because they are already trying to keep the premiums they charge for plans on the new state marketplaces as low as possible. Insurers are concerned about the potential for new costs, while patient advocates worry that mental health will be neglected.
Both sides say Washington is partly to blame. The federal government has yet to write the mental health act's final regulations for insurance companies, leaving a crucial gap between the intent of the measure and how it actually works.
Senator Kennedy's son, Patrick J. Kennedy, the former congressman from Rhode Island who was one of the law's main backers, said he worried that the Obama administration had delayed the rules because officials were preoccupied with the president's broader legislation and needed the insurance companies' support.
President Obama "needs the private insurers to implement this law or it's not going to work," said Mr. Kennedy, who has talked openly about his struggles with depression and bipolar disorder. He has held hearings on mental health issues across the country to talk to patients and their families, including one earlier this year where Cathy Morelli spoke.
Insurance companies, for their part, say they would welcome final rules under the 2008 law.
"We think it may create better clarity," said a spokeswoman for Aetna, which says it fully supports the 2008 parity law.
This article has been revised to reflect the following correction:
Correction: September 28, 2013
An earlier version of this article misidentified the president who signed the Mental Health Parity and Addiction Act of 2008 into law.
It was George W. Bush, not Barack Obama.
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