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The new warning sign reaches out five feet and adds LED lightning, so it can be seen at any time. Only six months in, the district is already seeing the impact.

Myers is at least the sixth St. Louis-area superintendent to depart from their role in the past four months.

ST. LOUIS - Traffic was backed up for an extended period after a tractor trailer overturned on Interstate 55 early Tuesday morning. The accident occurred a little after 5:15 a.m. Tuesday morning on northbound I-55 near Carondelet Boulevard in south St. Louis City. One lane remained open as crews tried to clear the scene. This [...]

Police are investigating a late-night murder in north St. Louis, while an adult male who was shot Sunday night remains in critical and unstable condition.

A favorite part of vacations is eating all the food. On Daniel Neman's trip to the beach, he was the one who was eaten.

Three major pharmaceutical companies and their national lobbying organization are suing Missouri to block enforcement of a new state law requiring them to give medical providers unlimited access to discounted drugs for their pharmacies. In four federal lawsuits filed over the past month, Novartis, AstraZeneca, Abbvie and PhRMA, the lobbying arm of the pharmaceutical industry, […]

by Annie Waldman and Maya Miller

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Accessing mental health care can be a harrowing ordeal. Even if a patient finds a therapist in their network, their insurance company can overrule that therapist and decide the prescribed treatment isn’t medically necessary.

This kind of interference is driving mental health professionals to flee networks, which makes treatment hard to find and puts patients in harm’s way.

ProPublica sought to understand what legal protections patients have against insurers impeding their mental health care.

Most Americans — more than 164 million of them — have insurance plans through employers. These are generally regulated by federal law.

Although the law requires insurers to offer the same access to mental health care as to physical care, it doesn’t require them to rely on evidence-based guidelines or those endorsed by professional societies in determining medical necessity. Instead, when deciding what to pay for, the government allows insurers to set their own standards.

“If insurers are allowed to home bake their own medical necessity standards, you can pretty much bet that they’re going to be infected by financial conflicts of interest,” said California psychotherapist and attorney Meiram Bendat, who specializes in protecting access to mental health treatment.

Federal lawmakers who want to boost patient protections could look to their counterparts in states who are pioneering stronger laws.

Although these state laws govern only plans under state jurisdiction, such as individual or small-group policies purchased through state marketplaces, experts told ProPublica they could, when enforced, serve as a model for broader legislation.

“States are laboratories for innovation,” said Lauren Finke, senior director of policy at The Kennedy Forum, a nonprofit that has advocated for state legislation that improves access to mental health care. “States can take it forward and use it for proof of concept, and then that can absolutely be reflected at the federal level.”

ProPublica reporters delved into the laws in all 50 states to determine how some are trying to chart new paths to secure mental health care access.

Many of the new protections are only just starting to be enforced, but ProPublica found that a few states have begun punishing companies for violations and forcing them into compliance.

Who Defines What Mental Health Care Is Necessary? Note: ProPublica included only states that had requirements specific to mental health coverage; we did not include states that had requirements only for substance use.

Insurers generally face few limitations on how they define what kind of mental health care is medically necessary. They often create their own internal standards instead of relying on ones developed by nonprofit professional medical societies. These standards can then be used to challenge diagnoses or treatment plans.

“Knowing the profit motive that insurers have, it’s really shocking that federal law doesn’t define medical necessity and require the use of nonprofit guidelines to make decisions,” said Bendat, who helped California legislators draft a more robust law that passed in 2020, becoming one of the first states to do so.

California’s law requires insurers to follow generally accepted standards of care for mental health and substance use conditions, forcing them to rely on evidence-based sources that establish criteria, such as nonprofit professional organizations or peer-reviewed studies. The state also barred insurers from covering only the treatment of short-term or acute symptoms, such as crisis stabilization, instead of the underlying condition, like chronic depression.

Last October, California found health care organization Kaiser Permanente in violation of the new state law and other health care regulations, reaching a settlement with the company, which agreed to pay a $50 million fine and make $150 million in investments in behavioral health care. A Kaiser spokesperson said that the company takes full accountability for its performance and that it had adopted new guidelines in line with the law. (Read their full response.)

A spokesperson for the state’s Department of Managed Health Care said the agency is auditing insurers and determining whether their networks offer enough providers to serve customers and whether they deliver timely access to care.

Nine states, including Oregon, Illinois and Georgia, have defined the clinical standards or criteria that insurers must use when making coverage decisions on mental health care.

Amid the opioid crisis, which has killed more than a million Americans, states have also instituted medical necessity protections for substance use treatment. For example, in Colorado, Maryland, Delaware, Connecticut and several other states, insurers must rely on guidelines from the American Society of Addiction Medicine when reviewing treatments for substance use.

How Can Insurers Challenge Mental Health Treatment? Note: ProPublica included states that had requirements for either mental health or substance use coverage. We did not include states that have these requirements only for autism coverage.

Before 2008, insurance companies nationwide could put more stringent limits on how often patients got mental health care compared with medical care, instituting more restrictive caps on the number of therapy sessions per year or the length of a stay at an inpatient facility.

The federal Mental Health Parity and Addiction Equity Act banned those harder limits. So insurers shifted to a different way to deny care. “They’re not going to just cover unlimited care, so they have to do something to limit utilization,” said Tim Clement, the vice president of federal government affairs at the nonprofit group Mental Health America.

Insurers say they conduct what they call utilization reviews, in which they can request and sift through therapy progress notes full of sensitive details, to assess whether providers are delivering appropriate care. However, providers, mental health care advocates and legislators have found that these reviews are often used as pretexts by insurers looking for a reason to dispute the necessity of treatment.

In recent years, at least 24 states have passed legislation to try to regulate how insurers conduct reviews of behavioral health care.

After the New York attorney general determined that insurers, including EmblemHealth, Excellus and MVP, had violated state and federal laws with their reviews, state legislators bolstered oversight of these processes in 2019. An Excellus spokesperson said it had since adopted several reforms; MVP did not respond to ProPublica’s questions, and EmblemHealth forwarded a response from a managed health plan trade group called the New York Health Plan Association, which said that the state’s findings do not reflect the industry’s current practices. (Read their full responses.)

The New York law requires insurers to rely on criteria based on evidence and approved by the state when scrutinizing care. Peer reviewers, who work for insurance companies to assess medical necessity or appropriateness of care, must be licensed providers with relevant expertise in mental health. And when it comes to children, insurers are generally prohibited from requiring preapproval for their mental health treatment or conducting reviews during the first two weeks of an inpatient stay.

Last year, New York regulators found that Cigna’s and Wellfleet’s medical necessity criteria were out of compliance with the new law. The insurers are allowed to keep operating while they work with the state to bring their criteria in line with the law, according to the state’s mental health office. (The companies did not respond to requests for comment.)

Several states, such as Massachusetts, New Mexico and Hawaii, make insurers disclose to patients and providers the criteria or policies that they rely on for reviews.

Insurers usually select the clinician conducting reviews, but in Illinois, if there’s a disagreement about the necessity of a treatment, a patient can opt for another clinical reviewer, jointly selected by the patient, their provider and the insurer.

Some states have also limited the frequency of reviews. In Delaware, insurers are generally prohibited from reviewing inpatient substance use treatment in the first 14 days. In Kentucky and Ohio, for patients with autism, insurers cannot request more than one review annually for outpatient care.

What Must Insurers Reveal About Mental Health Care Access? Note: The mandated reporting may include metrics on utilization processes, spending and outcomes in mental health.

It can be hard to enforce the laws requiring equitable coverage for mental and physical conditions; doing so entails comparing very different kinds of health care and successfully arguing there is an imbalance in access. State and federal regulators also have minimal resources for such intensive examinations, which has hindered their ability to scrutinize insurers.

To hold insurers accountable, at least 31 states and the District of Columbia have passed laws requiring them to report how much access they really provide to mental health care.

Most of these states ask insurers to provide details on their treatment criteria or limitations, but some states appear to be violating their own laws by not posting information publicly.

New Jersey’s Department of Banking and Insurance, for example, must make an insurer complaint log publicly available and post an insurance compliance report related to mental health care. But no such information has been published on its website more than five years after the state passed this requirement.

After ProPublica asked about the lack of transparency, spokesperson Dawn Thomas said that the department is working to implement the requirements and that the reporting process would begin this year. “We recognize that the reporting provisions in the law provide important public insight into compliance of carriers,” she told ProPublica in an email.

Chris Aikin, a spokesperson for the original bill’s primary sponsor, New Jersey Assembly Speaker Craig Coughlin, told ProPublica his office had been in contact with the department and would “monitor their progress to meet reporting requirements and ensure full transparency for consumers.”

For compliance reports, states often request data and analyses from insurers, but the figures that insurers submit may not be detailed or even accurate.

“I’ve reviewed a lot of these analyses,” said Clement, who has helped advocate for greater insurer transparency in multiple states, “and in most states, they’re pretty bad.”

But in some states, like Oregon, where detailed annual reporting is required, analyses revealed a disproportionate number of insurance claims for behavioral health were out-of-network compared with medical claims, suggesting that people may have faced trouble accessing therapists covered by their insurance plans.

Its reports also found that mental health providers were paid substantially less than medical providers for office visits of equivalent length. For an hourlong office visit, a mental health provider was, on average, reimbursed about half the amount given to a medical or surgical clinician. A spokesperson for the state’s Department of Consumer and Business Services told ProPublica that there have been no investigations or enforcement actions in response to the new requirements.

“There’s no way we can feel confident that anyone is following the law unless we make sure there is accountability and they have to prove that they’re accountable,” Clement said.

Other states, like New York, have begun to use the new data to drive investigations. Since 2021, the state’s Department of Financial Services has conducted nine investigations of seven insurance companies in response to the laws, according to a department spokesperson.

People can file complaints with their state insurance departments if they believe that an insurer is violating their rights.

We’re Investigating Mental Health Care Access. Share Your Insights.

Max Blau contributed research. Maps by Lena Groeger.

If you have submitted a complaint to a state insurance department that you would like to share with ProPublica reporters, you can email us at mentalhealth@propublica.org.

ProPublica reviewed laws and regulations in all 50 states and the District of Columbia. If you see a state law that was not included, please send us a note.

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In about a month, the longtime arts center in Alton will be moving from its current building — with no official plan to return. What’s led to the departure of the Jacoby Arts Center from that building has some Metro East residents worried about what’s to come. St. Louis Public Radio’s Will Bauer reports on the uncertainty for a staple of downtown Alton.

The former journalist hopes to parlay his name recognition into a seat in Congress.

ST. LOUIS - We made it to 100 degrees on Monday afternoon and will likely do that again Tuesday. A Heat Advisory has been issued as peak afternoon heat indies will be between 105 and 110. Please stay cool and hydrated and limit time spent outdoors in the hottest hours of the day. Overnight, there [...]

The shooting happened near the intersection of Cora and Evans avenues.

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The problem is the poll, shared exclusively with the Prospect, also shows that voters don’t believe the Biden-Harris administration has already taken action.

by Doug Bock Clark

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Update, Aug. 27, 2024: On Monday, the Democratic Party of Georgia and the Democratic National Committee, along with Democratic members of the Georgia Legislature and five metro Atlanta county election boards, filed a lawsuit against the Georgia Election Board challenging its new certification rules. “To remedy these harms and prevent chaos in November, this Court should follow decades of binding precedent,” the lawsuit stated, seeking a declaration that “election superintendents must certify election results.”

The members of the Georgia State Election Board could not have been clearer. Back in May, four of them voted down a proposed rule that would have given county election boards a new way to delay or reject election results, which could throw the November vote count into chaos.

“You run counter to both the federal and the state law,” said Ed Lindsey, a Republican board member and attorney who practices election law, to the woman who proposed the rule.

This rule “violates federal law. It also violates state law,” said Sara Tindall Ghazal, the board’s lone Democrat.

“It’s just not ready for prime time yet,” said the board chairman, noting that it needed more work to ensure its legality.

Even the lone board member supporting the rule, Janice Johnston, a retired obstetrician who had made unvalidated claims about falsified vote tallies in Fulton County, voted against it. The fifth board member did not vote. The board agreed that two members would work on improvements to the rule.

Three months later, a new draft of the rule came back for a vote. This time, it passed 3-2.

How much did the rule change between drafts? A review by ProPublica shows: hardly at all. In fact, election law experts told ProPublica that the small changes made the rule even less compliant with existing law.

The rule dramatically expands the authority of county officials overseeing the usually mundane task of certifying elections. The passage of it was enabled by nationally prominent election deniers and the Georgia Legislature. And the board members who passed it were cheered on by former President Donald Trump. It comes at a time when Trump and his allies are already calling into question the fairness of the elections process and making preparations to contest the results — and as Trump slips behind Vice President Kamala Harris in swing state polls.

It’s no coincidence that Trump allies are expanding their powers over certification in Georgia, a state where Biden beat Trump in 2020 by fewer than 12,000 votes.

Weeks after that election, Trump called Georgia Secretary of State Brad Raffensperger and asked him to “find” him those winning votes. Raffensperger refused. Since then, the Legislature has made numerous moves to exert more control over the state’s elections.

In the 2021 legislative session, lawmakers stripped Raffensperger of his spot as the designated chair of the State Election Board. Instead, they gave themselves the power to appoint the chair, unless they were out of session, in which case the governor could do it. (Though they could replace that chair once they were back in session.)

Another of their changes came this past May, after Lindsey, the Republican board member who had called the rule illegal, was pressured to resign. The Republican speaker of the House replaced him with Janelle King, the former deputy state director for the Georgia Republican Party and a conservative media personality, who has no experience in election administration and who had tweeted “I have questions!!” about the results of the 2020 election.

With King, the board became stacked with a majority of members who had questioned the results of the 2020 election. In early August, Trump praised all three by name during an Atlanta rally, calling them “pit bulls fighting for honesty, transparency and victory.”

Meanwhile, the proponents of the rule — including Bridget Thorne, a Republican Fulton County commissioner who calls herself the rule’s “originator” — decided to resubmit it. Thorne told ProPublica that claims of the rule’s illegality were an attempt to “scare” her. “I went and I talked to the lawmakers,” she said, “and they didn’t see anything wrong with my rules.”

Thorne said she got advice and support on the revised rule from Hans von Spakovsky, a Heritage Foundation lawyer who has led efforts for stricter voting laws nationwide for decades; Ken Cuccinelli, a former Virginia attorney general and the chairman of the Election Transparency Initiative, a group advocating for Republican priorities in election law; and Cleta Mitchell, the head of the Election Integrity Network, a nationwide organization that has challenged the legitimacy of American elections, which secretly backed the submission of the rule. Mitchell had joined Trump on the call in which he asked for Raffensperger to find him votes.

In response to questions from ProPublica, Cuccinelli provided a statement claiming that the authority the rule grants county board members is compliant with the law: “According to existing law, in signing a certification county board members are attesting subject to felony prosecution that the vote count is accurate. Obviously, each of them is expected to make that determination themselves otherwise there would be no point to having boards or board members.”

Mitchell and von Spakovsky did not respond to requests for comment.

The resubmitted rule only changed in minor ways between being voted down in May and approved in August. Those changes did not fix its legal problems, according to five election law experts who spoke with ProPublica. In fact, they said, in some ways it made them worse.

At the heart of legal experts’ critiques of the rule is its assertion that officials have the discretion to delay certification, even though more than a century of Georgia case law and judicial history says otherwise.

“If the State Election Board decided that the first rule was outside the role of their authority, I think the second rule is even more outside the scope of their authority,” said Caitlin May, a voting rights attorney for the American Civil Liberties Union of Georgia.

The only substantial addition was a new paragraph that gives county election boards the power to determine “a method to compute the votes justly” if they discover any error or fraud, while also requiring that a board report fraud to the district attorney. Legal experts worried that some conservative county boards might interpret this as permission to adjust vote counts they perceived as tainted, given that the rule doesn’t define what it means to “compute the votes justly.”

Georgia law states, “If any error or fraud is discovered, the superintendent shall compute and certify the votes justly, regardless of any fraudulent or erroneous returns presented to him or her.” (Italics added by ProPublica.)

Peter Simmons, a lawyer for Protect Democracy, a nonprofit that works to protect the integrity of American elections, said that by dropping “and certify” from the rule, its meaning has arguably been reversed. Instead of emphasizing that certification is a mandatory duty regardless of any fraud or errors, the rule tries to grant county election board members discretion not to certify by leaving out the language that they “compute and certify,” according to Simmons.

“This rule’s slight change in wording from the statute could have significant effects” and could “jeopardize Georgia’s ability to comply with the federal certification deadline,” Simmons said.

There also was a minor adjustment to the May version of the rule, which would have required that county boards meet on 3 p.m. the Thursday after the election to investigate potential errors. After criticism from Georgia election officials, among others, that the timing of such a meeting was well ahead of the 5 p.m. Friday deadline for counting provisional ballots, the August version of the rule moved the timing to 3 p.m. on Friday. But experts warned that the later timing still could cause provisional ballots to be missed.

Johnston had voted against the rule in May and for it in August. She was joined by Rick Jeffares, who did not cast a vote in May, and King.

In the August meeting at which the vote was held, Johnston argued that certification should be discretionary not mandatory, but she offered little explanation of her reasoning for supporting it after she previously voted it down, except to say that the change to the timing of the investigatory meeting had eased her concerns.

When asked why she had changed her vote, Johnston emailed ProPublica, “The small changes were appropriate.”

Jeffares and King did not respond to requests for comment.

Update, Aug. 27, 2024: This story has been updated to include a response from Ken Cuccinelli. His comment was sent before the story published but was caught in a spam filter.

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With electricity demand spiking, the Southern Company has opted to keep burning fossil fuels.