Comment; The purpose of health insurance is to pay for expensive care. I understand that it’s a competitive business & cost is a major factor. Care denial needs to stop. Physicians are regulated much less than insurers who REALLY need overwatch!
By Patrick J. Kennedy and Sean Scanlon Published 11:13 am EDT, Friday, April 12, 2019
Connecticut residents with behavioral health conditions should receive treatment just as easily and affordably as they would for any physical ailment, such as diabetes or cancer. Yet, more than a quarter of adults with serious psychological distress in the past year reported an unmet need for mental health care.
At a time when life expectancy is decreasing due to overdoses and suicides, we need to ensure that everyone has access to the services they need. Congress and the Connecticut state Legislature have passed laws requiring parity for diseases of the brain and body. But until tougher enforcement mechanisms are added, the true intent of those laws will not be met and, as we’ve unfortunately seen, insurance companies will continue discriminating against those with behavioral health issues.
In the recent class action lawsuit Wit v. United Behavioral Health, a federal court found that UBH, the nation’s largest managed behavioral health care company, rejected insurance claims of tens of thousands of people seeking mental health and addiction treatment based on defective medical review criteria and was wrongly influenced by a financial incentive to suppress costs.
The court found that UBH created its own flawed criteria to deny that treatment. Connecticut law requires insurers to use evidence-based medical necessity criteria for substance use disorders that are consistent with criteria developed by the American Society of Addiction Medicine, which means UBH’s criteria were not in compliance with state law.
For those needing mental health or addiction treatment services, an insurer’s flawed criteria can mean the difference between life and death. That’s because when coverage is denied, patients are left to foot the bill. Many can’t afford treatment or don’t get enough treatment to support long-term recovery. In 2016, more than 300,000 Connecticut residents experienced serious psychological distress. During that same year, 41.3 percent did not receive mental health treatment because they could not afford it.
The court also ruled that UBH’s guidelines improperly required reducing the level of care, such as removing patients from residential treatment programs to some form of outpatient therapy, even if their providers believed — consistent with generally accepted clinical standards — that maintaining a higher level of care was necessary. Doctors, not insurers, should be calling the shots when it comes to treatment.
The Wit v. United Behavioral Health ruling sends a clear message to insurers, but Connecticut regulators, employers and legislators must consider the implications, as well.
Given the federal court’s findings about violations of Connecticut law, the state has a duty to hold UBH accountable, including identifying all claims in Connecticut for which UBH used illegal criteria, requiring that UBH reprocess these claims under the supervision of the Connecticut Insurance Department and an independent monitor at UBH’s expense, and forcing UBH to reimburse consumers and providers for wrongly denied care.
On the policymaking front, the Connecticut Insurance and Real Estate Committee has passed legislation this session aimed at improving mental health and substance use coverage for Connecticut residents.
House Bill 7125 bolsters the Mental Health Parity and Addiction Equity Act of 2008 (The Federal Parity Law) by ensuring that insurance companies are meeting state mental health and substance use requirements. It would also require that insurance companies cover prescription drugs for substance abuse services, regardless of how that prescription is prescribed, without mandatory requirements for doctor’s approval for medication and step therapy. As the Wit ruling shows, without greater transparency and accountability from health plans and the Connecticut Insurance Department, parity may never be prioritized.
For far too long, we have not been able to attain true mental health parity due to a lack of enforcement. The Wit ruling has the power to spark lasting change if we heed its warnings and act now. By passing House Bill 7125, we can put an end to these harmful practices and ensure mental health and substance use disorder parity for the people of Connecticut once and for all.
Patrick J. Kennedy is the founder of The Kennedy Forum and, while serving as a U.S. representative (D-R.I.) from 1995 to 2011, was a co-author of the Federal Parity Law. The forum’s Don’t Deny Me campaign educates consumers about their rights under the Federal Parity Law and connects them with essential appeals guidance and resources.
State Rep. Sean Scanlon, D-Guilford, has represented the 98th District since 2014 and serves as chairman of the Legislature’s Insurance and Real Estate Committee.