Despite law, parity in mental health and addiction treatment can be elusive

©iStockphoto.com / KittisakJirasittichai
©iStockphoto.com / KittisakJirasittichai
Posted: March 07, 2016

Five years ago, Valerie Furlong's life was in turmoil.

Both of her teenage sons, raised in South Jersey about 20 minutes from Camden, had become addicted to opiates.

Yet when she tried to get them into rehabilitation centers, one of them was denied outright and the other was deemed ready for outpatient care after just two weeks, which would have put him right back into the environment where he became addicted - before it was safe to do so, Furlong said.

That experience led Furlong to dedicate herself to ensuring that a 2008 federal law that requires insurance plans that cover mental illness and addition to treat those conditions the same as physical ailments.

"When I started getting these letters of denial and realized that many people would not be able to deal with it, I decided that I was not going to go away quietly," said Furlong, who estimated that she and her husband have spent $50,000 to $60,000 on their sons' care because of insurance denials.

Besides pursuing multiple appeals, Furlong also joined the New Jersey Parity Coalition, a group of organizations and individuals trying to eliminate inequalities in the treatment of those seeking help for mental illness and addiction.

Much remains to be done.

Eight years after the Mental Health Parity and Addiction Equity Act became law, it is not effectively enforced in Pennsylvania, New Jersey, and many other states, advocates said.

Patrick Kennedy, a former Rhode Island congressman who has battled addiction and who championed the law, described the federal parity law as a "medical Civil Rights Act" at a Feb. 23 meeting in Washington.

"We cannot automatically change attitudes and prejudices that exist toward people suffering from a brain illness, but what we can change today are discriminatory reimbursement practices that exist toward providing care for people with mental illness and addiction," Kennedy said at the meeting organized by the Kennedy Forum, which he founded in 2013 to improve behavioral health care.

Colleen Barry, a Johns Hopkins University professor, said it was too soon to judge the impact of the parity law and certain provisions of the Affordable Care Act on behavioral health care. Final regulations for the parity law did not take effect until July 2014.

"Advocates will tell you that insurers could flout the parity rules and nobody would ever know about it. Whether that's true or not is an empirical question," said Barry, who is codirector of the Center for Mental Health and Addiction Policy Research at Johns Hopkins.

As was the case with one of Furlong's sons, outright denial is not always the problem. The insurer approved a limited amount of residential care followed by outpatient treatment.

An industry representative said insurance companies strive for the proper level of care, and support the patient's right to appeal.

"Health plans have pioneered a variety of clinical programs and support tools to promote effective, evidenced-based care for patients and families who face behavioral health challenges. Health plans are working with patients across the country to get them the right care at the right time in the right setting," said Clare Krusing, press secretary for America's Health Insurance Plans, an insurance industry trade group.

"The reality is patients seeking care are afforded access. And if there is a lack of agreement about the level of care recommended, which is rare, clinicians and patients have the right to appeal - a patient right that our industry has long-supported.

"Suggesting that coverage decisions drive the mental health challenges we face in this country does a disservice to the ongoing efforts - involving all stakeholders - to improve the country's health system for those who need behavioral health care."

Good data would help clarify the debate over coverage. The Kennedy Forum and other advocacy groups are trying to accumulate that kind of information.

Among the Kennedy Forum's efforts is a partnership with Philadelphia's Scattergood Foundation to track progress in the implementation of the parity act on federal and state levels.

The U.S. Department of Labor is responsible for enforcing the law for self-insured companies. Since October 2010, its Employee Benefits Security Administration has conducted 1,515 parity investigations and cited 171 violations, a January report said.

States are supposed to enforce the law for large group, small group, and individual plans. States are also allowed to pass their own parity laws.

Tim Clement, policy director for the Kennedy-Scattergood joint effort, called ParityTrack.org, said that Connecticut, Illinois, and Rhode Island were among the states that have passed laws to enhance parity protection.

On the regulatory front, California and New York, which has reached five settlements with insurers on parity violations since 2014, have been at the forefront.

"New Jersey and Pennsylvania, they are not the gold-standard states," Clement said.

Insurance department spokesmen for those two states said officials review plans to ensure they comply.

Checking the documents is not nearly enough, experts said.

"I see families where the benefit book reads just fine, but the family can't access the benefit because of unreasonable utilization review barriers," said Greg Heller, a lawyer with the Philadelphia law firm Young Ricchiuti Caldwell & Heller L.L.C. who has represented individuals with parity complaints.

As a starting point, regulators should require insurers to demonstrate their compliance, Heller said, and they should also analyze how much care is actually being approved and how much is being denied.

U.S. Rep. Joseph P. Kennedy III (D., Mass.), Patrick Kennedy's cousin, introduced a bill in December that would require insurers to release much of that information.

Pennsylvania elected officials are not sitting still.

The Human Services Committee of the Pennsylvania House has scheduled an April 13 parity hearing.

The question is whether Pennsylvanians are "getting access to health care for mental health needs in the same magnitude or degree that they are if they had a broken arm or needed a hip replacement," said State Rep. Thomas Murt (R., Montgomery).

"We're not so sure that they are," said Murt, who chairs the subcommittee on mental health, a position that makes him a funnel for frequent complaints from people who run into roadblocks when seeking treatment.

Difficulty getting treatment does not always mean there was a violation of the parity law.

The law requires most insurance plans that cover behavioral health services to provide them under the same terms as other types of medical services, according to ParityTrack.org.

For example, that means deductibles, co-pays, and visit limits must be the same for mental and physical health services.

However, federal regulations left other standards unclear.

"The ambiguity centers on what's medically necessary," said Adam Nester, public policy and development manager at the Mental Health Association of Southeastern Pennsylvania, an advocacy group. It is hard to evaluate that on an individual case level because the insurers keep their decision-making methods under wraps, saying the process is proprietary, he said.

A common complaint by operators of addiction-treatment facilities is that insurers frequently deny coverage for residential treatment deemed medically necessary by staff physicians.

In July 2013, Seabrook House ended its contract with Aetna after receiving dozens of denials. The tax-exempt organization in Cumberland County remains out of network with Aetna.

Aetna said the Seabrook situation was unusual: "There have been no mental health parity violations, and only a few minor disagreements over medical necessity decisions and claims."

Scott Weisenberger, chief executive of the Malvern Institute, in Chester County, said one day last month that the for-profit had three patients in residential care covered by federal Blue Cross Blue Shield and wasn't getting paid for any of them because Malvern admitted them without waiting for preapproval.

"The rule in substance-abuse treatment is when the person is ready to go, you need to get them in as quickly as possible," Weisenberger said. "We will appeal, try to make the argument that they needed care."

Furlong, mother of the two South Jersey teenagers, who are now in recovery, said she will take her appeals as far as she can in a bid to change the system. She declined to identify the insurer because of her appeals.

"We were able to buy the time by paying the bills," she said.

"But for a family who can't pay for treatment, that's when, unfortunately, the discharge happens," Furlong said. "The person is not ready. They relapse, and many times they overdose or they end up in jail."

hbrubaker@phillynews.com

215-854-4651 @InqBrubaker

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