Insurance department report examines how providers cover treatment for substance abuse

March 06--New Hampshire providers say the insurance department's examination of how the state's top three insurance carriers cover treatment for substance misuse is "a good start."

But they say the long-awaited report, released last week, doesn't fully answer the real question: Are insurers abiding by state and federal "parity" laws that require them to cover mental health services the same way they cover medical and surgical treatments?

Alex Feldvebel, deputy insurance commissioner, said the report is part of a broader effort by the department "to remove obstacles to behavioral health services for New Hampshire, especially at this time when so many citizens of this state are struggling to deal with opiate addiction."

The department's market conduct examinations of Anthem, Harvard Pilgrim and Cigna "are not the end of the road," Feldvebel said; the agency is already planning follow-up reviews.

Courtney Gray is executive director of the New Hampshire Providers Association, which represents providers of alcohol and substance use disorder treatment.

She said one shortcoming in the insurance department's report -- which the department acknowledges -- is that it only looked at claims data from the first three quarters of 2015.

On Jan. 1, 2016, individuals enrolled in Medicaid expansion moved into plans that cover behavioral health and substance use disorder services. As a result, Gray said, she expects claims, denials and appeals would all be higher in 2016; she hopes the insurance department will go back to the carriers to examine their coverage last year.

"The report in and of itself is a great step, but ... it's just a step," Gray said. "And we need to continue to make sure these reviews continue to happen."

Gray also said the state should include other insurers, especially plans offered through the New Hampshire Healthy Families program.

Jennifer Patterson, health policy legal counsel for the NHID, said the goal was to get a baseline of how the three largest carriers were handling substance use disorder claims. The exam came in response to concerns raised by providers about their clients' access to such services.

The department looked at such issues as prior authorization, provider networks, claims and denial volume, the availability of medication-assisted treatment and compliance with parity laws.

Patterson noted the latter issue is a new area for regulators, "and all across the country, people are still trying to work through what it means to enforce the parity laws."

As part of its review of claims, state examiners brought in medical experts to review cases in which insurers denied prior authorization for substance use disorder treatment. Of 62 denials reviewed, experts agreed with 80 percent.

Cigna fared best in that aspect of the review; medical experts agreed in all eight cases that were denied. For Anthem, the experts disagreed with six of 34 denials.

Harvard Pilgrim had 22 denials during the study period; experts disagreed with three of those, and found there was insufficient information in three more.

To address parity, insurance examiners looked at carriers' policies to see if they were covering behavioral health the same way they cover medical/surgical procedures. And they found for the most part, the carriers had proper procedures in place.

One exception was at Harvard Pilgrim, which outsources its preauthorizations for behavioral health services to a third party, United Behavioral Health. The insurance department found that may be a parity violation, since there's no comparable preauthorization requirement on the medical/surgical side.

The department also asked for corrective action from Anthem, after the exam found the insurer did not include depression screening in its preventative health guidelines on its website. A company spokesman said it has addressed that.

Patterson said the department also plans to look further into reimbursement rates on the behavioral health side.

The good news out of the market conduct exam, according to Patterson, was that "all three carriers were compliant in most areas, in particular where the legal standards were clear."

And she said, "All of the carriers were committed to making whatever adjustments they need to make to ensure that consumers have access to services."

The biggest area of concern was the lack of data to compare overall rates at which claims were approved or denied, Patterson said. She said it's something the insurance department plans to pursue in the future.

"This is an important area for us because we need to be able to understand and compare the practices across carriers, and we can't do that if we don't have data that enables us to make those comparisons," Patterson said.

One concern became clear through the study: an overall shortage in New Hampshire of substance use disorder/behavioral health providers. Patterson said since the study took place, the carriers have taken steps to expand their networks of providers.

Insurers responded favorably to the report.

Colin Manning, director of public relations for Anthem, said, "We're pleased the department's examination reaffirms our commitment to ensuring all of our members have access to the appropriate level of care."

"The ongoing opioid epidemic has cast a bright light on the importance of treatment access, which is why we have worked to build capacity by expanding our network of substance use disorder providers," he said. "Given the size and scope of this epidemic, we are continuing to work with providers and public officials to address this serious health problem."

The report on Anthem can be viewed below:

In a statement, Harvard Pilgrim said the company "is committed to ensuring that all of our members have timely access to high quality behavioral health services, including services for substance use disorders.

"We work diligently to ensure our compliance with all state and federal laws in this area, including the parity laws. As was noted in the report, we have already worked with the Department to address the concerns that were raised and will continue to do so."

The report on Harvard Pilgrim can be viewed below:

And Mark Butler, Cigna's market president for New England, said in an email, "We appreciate the Department's findings, which are a strong indication that Cigna properly administers claims for substance use disorder treatment and is serving the needs of our customers in New Hampshire. ... At the same time, we recognize that the Department found some areas for improvement, and we fully intend to address those."

Butler said Cigna is committed to reducing opioid use among its customers by 25 percent by 2019 by identifying better ways to treat chronic pain and encouraging providers to follow CDC guidelines about prescribing opioids. "People who suffer from substance use disorders are living with a chronic disease," he said. "They need treatment and deserve compassion, not stigma and condemnation."

The report on Cigna can be viewed below:

Going forward, Patterson said the insurance department plans to look at additional carriers and time periods, particularly what happened in 2016 after Medicaid enrollees moved into private plans.

Patterson said the department also is committed to continued education and outreach so that consumers understand what they're entitled to and how to file appeals.

And she's encouraged that a new advisory committee, which includes representatives of insurers, providers, advocacy groups and the Legislature, will be tackling some of the issues raised in the report on an ongoing basis.

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