New York Attorney General Eric Schneiderman has been at the forefront of enforcing state and federal mental health parity laws and advocating for consumers seeking mental health and substance abuse treatment. The state of New York passed a mental health parity law in 2006, called "Timothy's Law," prior to the federal Mental Health Parity and Addiction Act, passed in 2008 by the Obama administration. These laws seek to ensure that mental health and addition are treated by health plans the same as physical illness. They require behavioral health coverage be no more restrictive than medical coverage in terms of financial requirements (co-pays, deductibles, etc.) or limitations on the number and frequency of visits to a provider.
While the new laws were welcomed by health care advocates and consumers, many health plans continued to deny or delay treatment for mental health and addiction. In this climate, Attorney General Schneiderman, who first assumed office in 2011, worked to enforce mental health parity laws and compel health insurance companies to provide coverage for consumers. His office provides a toll-free Health Care Bureau Helpline for consumers to learn about their rights, make a complaint about their insurer and get access to health care they are entitled to. The Bureau investigates insurers and providers, sometimes based on complaints from consumers, that ignore or fail to comply with the law. His office reached settlements, including levying hefty fines, with major insurers that failed to meet the behavioral health needs of their members.
We submitted the following questions to the Attorney General's office to gain insight into the approach his office has taken to help consumers, advocate for the law and hold insurance companies accountable.How and why did you get involved in advocacy around mental health parity laws?
Mental health and addiction recovery treatments must be regarded the same as other health insurance claims under the law. Attorney General Schneiderman has taken an aggressive approach to enforcing these laws and will continue to take on those who ignore the law, and by doing so, reinforce the false and painful stigma often associated with behavioral health conditions. The office is committed to enforcing New York State and federal mental health parity laws, which require health insurers to handle claims for mental health and addiction treatment services the same as medical claims.Is the Bureau currently advocating for any new legislation or policy initiatives relating to mental health parity?
Attorney General Schneiderman’s multi-pronged strategy to tackling New York’s evolving opioid epidemic includes enforcing mental health parity laws, obtaining settlements with major national and global health insurers to remove barriers to life-saving treatment for opioid use disorder, cracking down on drug trafficking rings, and urging health insurance companies to review their coverage and payment policies that contribute to the opioid epidemic.Have past settlement agreements with health insurers resulted in lasting change to consumers' ability to access mental health treatment?
To date, we have reached agreements with six health insurance companies in unprecedented enforcement effort of mental health parity laws – requiring the companies to implement sweeping reforms in their administration of behavioral health benefits, coverage of residential treatment for substance abuse, co-pays for outpatient treatment, and filing regular compliance reports with the Attorney General, among other reforms.What impact have fines had on the health plans?
Through careful monitoring of our agreements, we have seen marked decreases in denials for mental health related coverage, including substance abuse. In some instances, denial rates shifted from a 50% to 11% for substance abuse treatment - this kind of change is dramatic.We believe that by making examples of six plans, all plans are going to be much more careful in how they treat claims for mental health / substance abuse treatment Do you have any thoughts about setting up a process where individuals/consumers who have been wronged by health plans failure to meet their mental health needs can benefit from the penalties levied against insurers?
Our recent agreements with six insurance companies have ultimately provided over $2 million in restitution for members whose claims were improperly denied.What would you say to other Attorney Generals in other states about setting up a Health Care Bureau to enforce laws relating to mental health parity?
Having a consumer Helpline like the Health Care Bureau Helpline is key to providing a window into consumer complaints about health plan denials. Looking at patterns of consumer complaints will help to build a systemic case against a particular health plan. Establishing ties to providers is also a useful way to learn more about how providers and consumers are being treated by the health plans - and whether there might be something illegal/discriminatory going on.
Our Health Care Bureau safeguards the rights of health care consumers statewide through investigation of and enforcement actions against insurers, providers, drug companies, and other individuals and entities. The New York Attorney General’s Office hopes the Bureau’s work to enforce mental health parity laws can serve as a national model.
Advocates at MHAIP have reached out to Attorney General Schneiderman’s office in at least five cases with NY state enrollees, we have recovered all that we requested for four, and are waiting to hear back on a fifth case. We strongly encourage Attorneys General in other states to implement similar programs.
You can be your child’s advocate and secure ABA treatment through your health plan. Insurance coverage of autism treatment and services is required by law in 46 states and the District of Columbia, including ABA. To secure this medically-necessary treatment for your child, follow the steps below:1 Understand Your Health Plan - Fully-Funded or Self-Funded?
Determine if your plan is regulated by the state, referred to as fully-funded, or subject to federal regulation, a self-funded plan. If you are uncertain about whether you have a state regulated plan, check with your human resources department or the administrator of the plan.
Fully Funded: The laws vary slightly from state to state but if your plan is regulated by your state, there is an appeals process and other supports in place that ensure that plans meet their obligations under the law.
Self-Funded: These plans are exempt from state regulation. While there are fewer protections for consumers, many self-funded plans do cover autism treatments like ABA. Read through your Plan Description or contact the insurer to determine whether autism treatment is covered.
If your plan doesn’t explicitly exclude autism treatment, it is worth going through the authorization process (see the following section) to determine whether you can get coverage.2 Understand Your State's Insurance Laws
A list of states that require insurance coverage of autism services can be found at www.ncsl.org.
Locate your state’s mandate and bookmark the website for future reference. This information will also be useful if you need to file an appeal with the state regulator if your child is denied treatment.
Check where you plan is located. In some cases, your plan may be located in, and regulated by, another state from the one you live in. Read through your evidence of coverage for this information. You will need this information to file for an appeal against a decision to deny autism treatment.3 Seek Authorization
If your child has an assessment confirming a formal diagnosis of an autism related disorder, in most health plans, you can contact your health plan directly and request services. Some plans may have a a separate carve-out for behavioral health treatment. If your insurance has a separate division for behavioral health, you may need to make a request for services through this entity. The phone number should be on the back of your insurance card. Call them to request authorization for services. When asking for treatment, tell them you have a child with ASD and ask for a provider or list of providers experienced with treating autism.
If autism is suspected but your child has not had a formal assessment, you’ll want to call the same number on the card to request an assessment. In some health plans, you may need to get a referral from your child’s pediatrician.
TIP: Document all your correspondence with your child’s doctor and the health plan. For example, note the date and time and what was discussed - asking for a phone call log number if applicable. If you write an email or letter, keep copies for future reference.Options if you can’t get an authorization:
If, for some reason, you cannot get an authorization, ask to speak to a supervisor or a manager in that division. If they tell you they can’t authorize treatment, ask them why and what steps you need to take to get treatment authorized. Request a written denial letter, - in some states this can be useful in getting services from other entities (Medicaid, Departments of Disabilities, Regional Centers, etc).
They are usually required to respond to your request for authorization in less than 30 days, so take note of the date of your request and follow up with your health plan if you haven’t received a response.
TIP: If asking for authorization over the phone, write an email or letter summarizing the conversation as well as the date, time and representative you spoke to, through your health plan’s electronic system.
What to do if No Providers Are Available:
This is becoming an increasingly common problem, as there are more people that need services than there are qualified providers to serve them. The steps involved in exploring the plan network and requesting a single case agreement can be found here (scroll down to Network Insufficiency), which is useful if you know someone outside of the network that can serve your child. Increasingly, however, we get calls from families who are facing full networks and no place to go. When this happens, we encourage you to write up a letter explaining the situation, and file it with both your health plan and the state regulator. Information can be found here (scroll down to “No Available Providers.”) A sample letter can be found here.4 Appeal if Treatment is Denied
Despite the fact that ABA treatment is widely recognized as an evidence-based treatment for ASD, insurers may nevertheless try to deny coverage or cut back hours. In state-regulated plans especially, you have the law on your side. Even if you have a self-funded plan, you have appeal rights and it’s worth pursuing an appeal to secure ABA.
Submit an Appeal to Your Health Plan -
In some situations, you must first file an appeal with your health insurer, wait 30 days, and then involve your state’s health insurance regulator. If your child’s behaviors are rapidly deteriorating, you may be able to request an expedited appeal. More information on requesting expedited status for Californians can be found here (scroll down to “Requesting Expedited Status"). Your insurer must give you written notice of denial of coverage. The denial should include the basis on which they are denying treatment. Further, the denial letter should include what steps you can take to appeal the decision. If this information is not included, you can determine the appeals procedure by looking at your benefits handbook or contact the Member Services department and ask them what steps you can take to appeal the decision.
Write an appeal letter by referencing, and including, all supporting documentation that will help your child’s case:
*Evaluation or assessment diagnosing ASD
*Assessment from a treatment provider (psychologist, behavioral specialist, primary doctor)
*Letter from a provider outlining why ABA is medically necessary for your child.
If the denial alleges that care is not medically necessary, the plan must tell you why. Where necessary, correct the insurer’s information and back it up with information from the assessments.
Mail your appeal letter and all supporting document to your health plan via registered mail to document that you sent, and the plan received, the appeal. If you FAX the appeal, print the confirmation sheet. Your insurer usually has 30 days to respond to your appeal so follow up with them if you don’t hear anything after that time.
TIP: Even if you are first required to go through the health plan’s appeal process, you can contact your state’s regulator for help and advice on your case prior to filing an appeal with the regulator.
5 Contact Your State Regulator
If you have a fully-funded plan, identify the regulator for your state (www.ncsl.org) and look up the information for filing an appeal or a grievance against your health plan. In some states, you don’t have to wait for your health plan to respond to your appeal before involving the regulator. Call and ask what the specific policy is for your state.
The regulator will review your child’s case and all documents relating to the denial (assessments, referrals, denial letter, explanation of benefits, etc.) They will try to resolve the case with your health plan on your behalf.
In some cases, your child’s grievance may be eligible for an Independent Medical Review (IMR). An IMR is conducted by a physician or relevant specialist who is not affiliated with your insurer. They will review the case and decide if the health plan’s denial of treatment was appropriate and whether coverage should be provided.____________________________________________________________________
Pre-authorizations: MHAIP does pre-authorizations for families that contact us before their children start residential treatment or very early in their stays. Success rates are typically higher than when we go in after the fact. We recently won the following, all from United Health Care, at the residential level of care: 51 days of coverage for a 12 year old girl from Colorado with bipolar disorder and severe anxiety; 40 days of coverage for a 16 year-old boy from Tennessee with severe depression; 33 days of coverage for a 15 year old boy from Texas with mood dysregulation disorder and substance abuse. From Sanford Health Plan, we obtained 52 days of RTC coverage (and ongoing) for a 15 year-old girl with depression and anxiety and 22 days (and ongoing) for a 17 year old boy with severe depression, substance abuse, and oppositional disorder, both from South Dakota. We have won 188 days (and ongoing) residential for a 16 year-old California boy with autism, anxiety and severe depression from ComPsych.
Some plans allow requests after-the-fact. We obtained 102 days of residential coverage (and ongoing). in a retro-authorization from Care First for a 16 year-old girl with major depression and substance abuse from Maryland.
MHAIP recovered over 36K from Horizon Blue Cross Blue Shield for a seven week stay at a Wilderness program for an 18 year-old New Jersey youth with depression and substance abuse issues. Horizon had initially denied treatment, alleging that care was not medically necessary. We appealed, they upheld their denial. We then took the case to the New Jersey Department of Banking and Insurance, they agreed with us and ordered the plan to pay.
MHAIP helped a young man from New York with substance addictions get coverage for an additional 51 days of mental health residential treatment.
In our last newsletter, we reported that MHAIP had helped a 22-year-old man with depression and substance addictions obtain coverage for 50 days of residential mental health treatment. MHAIP had filed a successful complaint with the New York Attorney General, arguing that Beacon had unlawfully denied coverage for the type of care he received. Beacon then agreed to pay for the first 50 days of his care. Beacon, however, denied the remaining 51 days of his treatment, alleging it was “not medically necessary”. MHAIP then filed a successful appeal with the New York Department of Financial Services, and Beacon was required to pay for the remaining 51 days of his treatment. In total, we helped to recover over $89K, nearly 7K of which was interest.
MHAIP helped a family partially overturn a reduction of ABA hours. We assisted the family of a 15 year-old California boy to appeal the plan’s abrupt reduction of ABA therapy from 36 to 15 hours weekly. The basis of the insurer’s denial was that the number of goals did not support the need for the number of hours requested. After we filed an appeal, the plan overturned their decision and authorized 20 hours of ABA therapy weekly, including 2 hours of oversight and protocol modification. The young man receives therapy at home and in a mainstream classroom setting. MHAIP is currently helping the family with a secondary level appeal.
MHAIP wins Second Hour of Weekly Speech Therapy for 7 year old to learn AAC Device
A seven- year-old non-verbal boy with autism from Santa Clara County was repeatedly denied a second one-hour speech therapy session per week by Kaiser to support his use of an assisted adaptive communication device (AAC). Kaiser based their denial on the assertion that “there is no current medical evidence that shows an increase in the frequency of speech therapy will lead to an increased rate of development in speech and language skills.” MHAIP appealed to the DMHC and the DMHC agreed; the DMHC compelled Kaiser to provide an additional one-hour of speech therapy per week because a “children with autism benefit with improved receptive language skills with the use of an AAC device.”________________________________________
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