Even Minnesotans who have health insurance are increasingly likely to pay more to get mental health treatment compared to care for other medical issues.

It's part of a trend that's coming under greater scrutiny by insurance regulators in Minnesota and across the country.

A recent study that looked at three years of insurance claims, including nearly 7 million in Minnesota, has advocates concerned that the added cost burden for mental health treatment will discourage people from seeking help.

Regulators are asking if the situation violates a 2008 federal law named partly after the late Sen. Paul Wellstone. It requires any insurance coverage for mental health be at parity with coverage for medical care.

Health plans do a good job providing enrollees with a network of physicians to serve their medical needs, according to the research. A relatively small percentage need care from out-of-network doctors, usually a more costly option.

But when it comes to getting mental health care, enrollees went out of network much more often. That boosted the co-payments or coinsurance payments they needed to pay.

That can further complicate the search for treatment, a process made more difficult when people are at their most vulnerable.

"It is very discouraging when you call five different therapists and they aren't taking patients," said Natalie Berreth, 22, who had problems getting care for depression, anxiety and an eating disorder when she was a teenager.

"It can be incredibly isolating when you feel that you aren't getting help," she said.

In 2015, Minnesotans went out of network for mental health therapy at a rate eight times higher than they did to receive primary care and five times higher than care from specialty physicians. There were similar disparities for hospital and intensive outpatient care.

"We have been hearing from people that it has been hard to get in to networks and this confirms that," said Sue Abderholden, executive director of the National Alliance on Mental Illness-Minnesota. "Time has come to just stop discriminating against people with mental illness."

The problem is getting worse in Minnesota. In 2015, out of network mental health care jumped threefold, accounting for 11 percent of all therapy sessions, according to the study conducted by the consulting firm Milliman.

The Minnesota Commerce Department, which has regulatory authority over the mental health parity laws, said complaints are increasing — including from those forced into more costly out-of-network coverage because therapists in health plan networks were not taking new patients.

"The findings in the Milliman report align with the complaints that Commerce has been receiving over the past year and a half," said Peter Brickwedde, assistant commissioner of government and external affairs.

"While insurance companies are required to design a provider network that is adequate, consumers are struggling to access the benefits they are guaranteed under state and federal law," he said.

Aided by a $1.1 million federal grant, the department has stepped up education and enforcement of the parity law and is currently investigating possible parity violations.

The Milliman study pointed to one reason for inadequate networks: significantly lower insurance company reimbursements to mental health professionals who are in a health plan's network.

Comparing payment rates for standard office visits, Milliman found that psychiatrists in Minnesota were paid 40 percent less than primary care doctors and 35 percent less than specialty doctors, even though psychiatrists are licensed as medical doctors.

"Insurers are not maintaining adequate mental health provider networks," said Dr. Paul Goering, vice president for mental health at Allina Health and president of the Minnesota Psychiatric Society.

"We would like to have a mental health system that responds to the needs of everyone so we don't have to wait until people are in need of traumatic intervention and people have early access," said Goering.

The study did not look at payments to psychologists and other therapists. But Blue Cross and Blue Shield of Minnesota, the state's largest insurer, announced in August that it would be decreasing mental health reimbursements beginning next year.

"If they are paying a whole lot less that is a parity violation," said Abderholden. "One of the reasons that there is going to be more out-of-network care is because a lot of psychiatrists do not take insurance and now we see why."

Minnesota's three largest insurers said that their behavioral health care networks have remained stable or have been growing and that some enrollees get mental health care through their primary care doctor, something that was not reflected in the study.

They also said that selecting a mental health provider is a highly personal decision, one that might cause an enrollee to go out of network to get the best fit. Also, if employers switch insurance providers, networks will change and enrollees might choose to remain with a long-term therapist even though it would cost more.

Brickwedde at the Commerce Department said the state is exploring new ways to enforce the parity law, including systematic market reviews, "as complaints about possible parity violations started to come in that Commerce had not seen before."

These reviews would look at provider reimbursement, whether network providers were accepting new patients, prior authorization and policy exclusions — all factors that affect parity.

For Rhoda Michaelynn, who lost her son to mental health disease last year, the lack of parity means that health insurance is not doing enough to prevent conditions from escalating.

"Prevention is going to be much more worth their while than hospitalization," she said. "How many stories do we read of the parents of these kids who said we tried, we didn't have the money, we didn't have the support?"

Glenn Howatt • 612-673-7192