Substance abuse care coverage often denied

Dec. 13--If you think your insurance company has unfairly denied coverage for substance abuse treatment, the New Hampshire Insurance Department wants to hear from you.

The company could be breaking the law.

Last month, the department announced it was conducting an examination of the state's five largest health insurers, focusing on how those companies are covering treatment for what's known as "substance use disorders," or SUD.

"We need to know in more depth just exactly what's going on with these kinds of claims and whether or not the companies are complying with mental health parity," Insurance Commissioner Roger Sevigny told the New Hampshire Sunday News.

Federal law requires health insurers to provide coverage for mental health and SUD treatment that's equivalent to what they offer for medical/surgical benefits; that's called "parity."

But with the state in the midst of a deadly opioid epidemic, advocates say they hear from medical providers and consumers all the time who say that doesn't always happen.

Abby Shockley, executive director of the New Hampshire Alcohol and Other Drug Service Providers Association, said her members tell her that fighting for coverage of SUD services for clients is "a daily occurrence."

"I think we have a long way to go to actually achieve parity for behavioral health services," she said.

Officials say many Granite Staters may not even realize that these services are covered. While insurers are required to include an explanation of benefits in plan summaries, most consumers don't look closely at their policies, they say.

Alex Feldvebel, deputy insurance commissioner, said a 2008 federal law mandated parity if an insurer offers coverage for mental health and addiction treatment, but the regulations that implemented it only took effect last January.

Meanwhile, the Affordable Care Act broadened that mandate: mental health and SUD treatment is one of the 10 essential benefits plans must include. That took effect Jan. 1, 2014.

"So now parity does apply to all major medical coverage," Feldvebel said.

Digging in

It's typical for the department to do a "market conduct examination" to assess compliance with a law that recently took effect, Feldvebel said. "The law's set up that we have access to any information that is in the possession of the carrier, and the cost of the examination is borne by the carrier."

State regulators are looking at Anthem, Harvard Pilgrim, Cigna, Minuteman and Community Health Options.

"We're looking for any indication that they're being more restrictive in the way they handle claims for addiction treatment services and make those determinations of medical appropriateness than they are on the medical/surgical side," Feldvebel said.

Sevigny likened a market conduct examination to "the mechanic looking under the hood."

Michele Merritt, policy director at New Futures, said she's heard complaints from both parents and providers about denial of claims.

She cited a recent survey by the National Alliance on Mental Illness that found insurers were more than twice as likely to deny claims, based on medical necessity, for behavioral health than for medical services.

She expects regulators will find problems here as well. "I think there are definitely some questionable things that are happening, and I am very encouraged that the Department of Insurance has affirmatively gone ahead and started looking at what may be happening in the plans to see whether or not it is a more pervasive issue," she said.

Colin Manning, director of public relations for Anthem Blue Cross Blue Shield, the state's largest health insurer, said the opioid epidemic has stretched New Hampshire substance abuse infrastructure "to its limits."

"Clearly all of us -- families and friends, treatment professionals, providers, carriers, law enforcement and policymakers -- need to continue working in a coordinated, unified manner if we are to make progress in our fight against this problem," he said.

"As with any medical condition, we want to be sure members with substance use disorders have appropriate access to the care they need," Manning said. And he said Anthem is looking into "what ways we may expand access, including addressing any current limitations on capacity."

Merritt said it's easier to determine whether an insurer is following parity laws when it comes to co-pays or how many outpatient visits are covered. But assessing "non-quantitative" issues, such as how often they deny coverage for treatment they deem not medically necessary, can be more difficult.

Determining whether a carrier provides equivalent coverage can be complicated, Shockley said. However, she said, "I think the denials that we're seeing, if it's not a parity violation, it's a moral violation."

One of the most egregious examples, she said, involved a woman whose coverage for outpatient treatment was denied after three sessions because she "hadn't consumed alcohol in six weeks, so they were no longer (considered) a medical necessity."

But for the first three weeks of that period, the woman had been hospitalized and her spleen and part of her pancreas were removed due to alcoholic hepatitis.

SUD, Shockley said, means "a lifetime of being in recovery and avoiding substances, so I can't imagine that six weeks of treatment is enough for anybody."

Shockley welcomed a recommendation by a legislative task force on the opioid crisis to adopt uniform care standards from the American Society of Addiction Medicine that providers and insurers can rely on to make treatment decisions.

Navigating insurance

On Friday, New Futures teamed up with the providers association to train about three dozen licensed alcohol and drug counselors on the parity law.

Merritt said many individuals who really need SUD treatment may be in no condition to navigate the appeals process if coverage is denied. One goal of Friday's training was to teach care providers how to help their clients file complaints with the state insurance department if there appear to be parity violations.

Keith Nyhan is director of consumer services at the insurance department. His division has a threefold mission, he said: educating consumers who have questions about insurance products; helping folks connect with their carriers; and mitigating when a problem does arise.

The latter could mean recovering money if a claim was not paid, or helping a consumer get approval for a treatment that was denied.

"Our main goal here is to enforce the insurance laws," Nyhan said. "Whatever we can do to help consumers in that capacity is what we try to do."

From the complaints Nyhan has seen about coverage of SUD services, "It's not that treatment is being denied, but that inpatient treatment is being denied because outpatient treatment is available," he said.

Regulators expect to finish their market conduct examination and make their findings public next month.

Merritt said she hopes the department will share its findings with the U.S. Department of Labor, which regulates self-funded insurance plans. Many of the carriers that provide group and individual health insurance here also administer those plans, she noted.

The insurance department has a range of sanctions if it finds a carrier was not in compliance, including fines of up $2,500 for each offense, Sevigny said. "The ultimate penalty ... that we hold in our pocket -- that hopefully I never have to use, but it's there -- is we can pull a company's license," he said.

But the ultimate goal of an enforcement action, he said, is to change behavior: "to make sure the company complies with the law in the future and makes the consumer whole."

The NH Providers Association welcomes the state's action, Shockley said. "I really think this is an opportunity for the Insurance Department to be a leader and for New Hampshire to be a model for other states on how to enforce parity," she said.

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For questions or complaints about insurance coverage, contact the Consumer Services Hotline: (800) 852-3416.

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