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Comprehensive Mental Health Insurance Benefits:
Case Studies
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Office of Managed Care
VIII. Appendix C: Employer Case Studies
D. Fannie Mae Corporation
Company History / Profile
The Federal National Mortgage Association, also known as Fannie Mae, is a private, shareholder-owned company that purchases mortgages from primary lenders. Under a congressional charter in 1938, Fannie Mae operates a secondary mortgage market to increase money available for new home mortgages. In 1968, Fannie Mae became a private, self-sustaining corporation. Since this conversion, Fannie Mae has become number 26 on the Fortune 500 with 1998 revenues of $31.5 billion. Based in Washington, D.C., Fannie Mae has 3,800 employees in its offices throughout the Nation.
Factors Influencing Company's Decision to Provide Comprehensive Benefits
Fannie Mae recognizes that employee benefits promote recruitment, productivity, and retention. The company has developed a comprehensive set of fringe benefits in an effort to remain an industry leader. For example, in addition to generous 401(k) and stock purchase plans, Fannie Mae offers some unique financial benefits, including housing assistance programs and reimbursement for adoption expenses. The company also offers emergency child care, an elder care program with case management and other services for parents and relatives of employees, and a variety of flexible work options, including job sharing and telecommuting.
Mental Health Benefits
Description of Benefit Options
Fannie Mae offers several health coverage options: a PPO, two HMOs in each region, and a catastrophic indemnity plan. About 54 percent of employees are enrolled in the PPO, approximately 35 percent in an HMO, and 3 percent in the catastrophic plan. The remaining 8 percent have waived coverage. Employees choosing the catastrophic indemnity plan or waiving coverage often are covered under a spouse's health plan; they select these lower cost options so that they can purchase specialty coverage, such as vision care.
Fannie Mae contracts with Kaiser Permanente, HMO-Illinois, and Aetna U.S. Healthcare for HMO coverage. Aetna also manages the PPO and catastrophic indemnity plans. The company covers 100 percent of premiums for single employees and 60 percent of premiums for dependents, including spouses and domestic partners as well as natural, adopted, or step-children. Fannie Mae self-insures for all coverage options. Because most employees participate in the PPO, this case study focuses on that benefit option. Tables 9, 10, 11, and 12 outline benefits provided by each option.
Benefits under each plan include some restrictions. In the PPO, mental and inpatient physical health benefits operate through a gatekeeper. Although mental health patients must obtain precertification from Magellan Health Services, Fannie Mae places no limits on services approved by Magellan. Out-of-network rates apply to unapproved services. This gatekeeper system is designed to ensure appropriate utilization, allowing Fannie Mae to continue providing unlimited benefits. The company places a priority on unlimited care for patients in need. Inpatient physical and mental heath care face the same restrictions.
Since January 1, 1998, Fannie Mae has contracted with National Prescription Administrators to manage the PPO plan's pharmacy benefit. The plan requires a $5 copayment for generic drugs or doctor-required name-brand drugs at participating pharmacies (or $5 for a 3-month mail order supply). Fannie Mae covers medication purchased in out-of-network pharmacies at 80 percent. To receive a name-brand medication not specified by a doctor, a patient pays the cost difference between the name-brand medication and its generic counterpart. No distinctions are made between physical and mental health pharmaceuticals.
Employee Assistance Program
Fannie Mae has contracted with Value Options, Inc., to operate its external EAP since the program's inception in 1987. The program, providing assistance with mental health, substance abuse, financial, and legal problems, most often deals with marital and family conflicts. Employees can receive up to seven sessions per incident. In 1998 and 1999, between 7 and 9 percent of Fannie Mae employees used the EAP.
Although the EAP has no on-site presence, Fannie Mae attempts to increase awareness and improve utilization. The company does not have an official structure enabling managers to refer employees to the EAP; managers informally pass information along when necessary. Fannie Mae also offers seminars and lunchtime programs during which employees can learn more about a variety of topics, including the EAP.
Benefit Management
Fannie Mae administers its health benefits through three internal groups: the Compensation and Benefits Department, the Human Resources Service Center, and the Health and Work Life Center. The Human Resources Service Center handles everyday administration of the benefits plan and operates a hotline for employee questions or complaints about their benefits. Issues about the benefits policy go to the Compensation and Benefits Department, which acts as plan purchaser, monitors plans' performance, and manages official communication with vendors. Fannie Mae reviews its health insurance vendor contracts annually.
While benefits administrators refrain from direct involvement with managed care vendors, the consulting psychiatrist often works as a direct employee advocate. Through case management responsibilities, the psychiatrist monitors providers and MCOs. The consulting psychiatrist spends approximately 10 to 15 percent of his or her time seeking precertification for treatment or questioning denials of coverage.
Key Program Components / Best Practices
Under the authority of the Health and Work Life Center, Fannie Mae encourages wellness through initiatives designed to promote healthy living and to help employees balance home and work life. The Center also provides limited treatment through staff nurses and part-time, on-site physicians, one specializing in primary care and one in mental health.
- On-site psychiatrist acts as lead mental health resource.
One of Fannie Mae's direct attempts to improve mental health care came 8 years ago when it hired a part-time, on-site psychiatrist.
The psychiatrist meets with employees in a nonclinical setting, gives advice, and makes referrals to the EAP or the benefits plan; he conducts approximately five consultations (direct contact, review of records, and telephone review of regional cases) each week. An employee can consult the psychiatrist for any reason and as often as needed. The psychiatrist also serves as a case manager for mental health care, maintaining contact with the provider to ensure appropriate access to and quality of treatment. Another level of employee contact involves resolving health-related workplace issues through a collaborative effort including the treating physician; the human resources, Health Services, and Legal staffs; and Fannie Mae management.
The consulting psychiatrist also works as part of an integrated team with Security, Legal, Health Services, Human Resources, and senior management to respond to potential acts of workplace violence. In addition, he consults with the corporation concerning its mental health benefits and provides feedback on the EAP and the mental health benefits plan. The current psychiatrist's interest in the integration of mental and physical health care has led to an increased awareness by Fannie Mae leadership of the need to provide comprehensive mental health benefits and to facilitate the integration with physical health care.
- The Partnership for Healthy Living program assesses employee health.
The Partnership for Healthy Living program, operated by HealthOne, Inc., provides all Fannie Mae employees with free annual health assessments, including medical and behavioral health screenings. Participants complete a comprehensive health questionnaire and receive a Personal Wellness Profile outlining their overall wellness and ratings in specific areas. The Partnership for Healthy Living stresses a holistic approach to wellness. In addition to physical health and lifestyle questions, the questionnaire addresses behavioral-health-related topics such as substance abuse, stress, depression, anxiety, suicide, coping, social support, social activity, and violence. The profile also includes general and personalized information to educate employees about controlling substance abuse, managing stress, and improving mental health. After receiving the profile, participants can attend group counseling sessions that address the results of the screening. Fannie Mae encourages employees to complete the assessment and counseling session, offering a "healthy living" vacation day as an incentive.
- Educational programs increase awareness about wellness issues.
The Health and Work Life Center sponsors a variety of educational programs on topics such as stress reduction, depression, alternative medicine, ergonomics, and other wellness and mental health concerns. Furthermore, specific programs offer information sessions to familiarize employees with their services. The on-site psychiatrist takes an active role in some of these educational programs.
Employee Satisfaction / Performance Data
Fannie Mae uses several formal and informal instruments to assess its health benefits. The company monitors customer satisfaction with provider service through performance measures such as telephone hold times and timeliness of claims payments. Fannie Mae evaluates EAP success quarterly, looking at utilization, cost, and number of cases resolved. The consulting psychiatrist provides input into the comparison of the current vendor to competitors' services.
Both Fannie Mae and its managed care vendors conduct employee satisfaction surveys. Fannie Mae also assesses employee satisfaction through its hotline (operated by the Human Resources Service Center) and tracks employee complaints and responds to issues that are raised frequently.
Benefits staff, Health and Work Life Center employees, and the consulting psychiatrist note less concrete performance measures such as general perceptions of employee satisfaction or direct feedback from employees, the EAP, and colleague physicians. The Health and Work Life Center staff tracks sick leave, short- and long-term disability, and workers' compensation.
The most prevalent problems reported relate to the provider network. Aetna's merger with U.S. Healthcare created network turnover, forcing a number of employees to change providers or to pay additional fees to see the providers of their choice. Fannie Mae is concerned about access to mental health services under the managed care plans. Although the company recognizes the value of a gatekeeper, it also believes that precertification can pose a significant barrier to care, requiring a prospective patient to place a telephone call and pass through numerous menu levels of electronic telephone management.
Fannie Mae plans to design an instrument to track the relationship between utilization of mental health care service and productivity. By measuring clinical, financial, and attendance data as well as the impact of care on the relationship between managers and employees, the outcome of care at work, and the impact on the patient's family, Fannie Mae will get a more systematic assessment of the effects of mental health benefits.
Lessons Learned and Challenges Remaining
Fannie Mae's focus on mental health has resulted in an increased awareness of the direct relationship between overall wellness and employee productivity. Through its benefits plan and programs to maintain employee physical and mental health, Fannie Mae has learned valuable lessons and identified several remaining challenges.
Lessons Learned
- Employee well-being is affected by mental as well as physical health. Physical conditions may have underlying, comorbid mental illnesses. Furthermore, mental health problems generally are more prevalent than assumed; companies must provide diverse and effective treatment options for employees who need help.
- To ensure quality and accessible care under MCOs, a company must advocate on behalf of its employees. This interaction can come directly from the purchasing office or through a consultant, such as Fannie Mae's on-site psychiatrist. Official responses are more effective than individual complaints at enticing the MCO to cover specific treatments.
- Development of a comprehensive mental health benefits plan is an ongoing process; plan design is dynamic. A company should monitor its mental health benefits and work to improve them often and proactively.
Challenges Remaining
- Fannie Mae is improving the integration of physical and mental health care. The company continues to study the impact of mental health on productivity, absenteeism (including short- and long-term disability), and employee well-being.
- Fannie Mae is working to ensure access to mental health care by becoming a more effective manager of providers and MCOs. The consulting psychiatrist provides case management of employee care; the company is working to streamline this process and to improve overall access to care.
- Fannie Mae hopes to end regional variations in its benefits plan by encouraging its HMOs to offer consistent benefits. For example, Maryland, Virginia, and District of Columbia employees all receive slightly different HMO mental health benefits because of varying State regulations.
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