Your physical and mental health are considered equally important under state and federal law. It's called “mental health parity.” Insurers haven’t always complied. State lawmakers' recent actions intend to take hurdles from insurance out of the long path to recovery from addiction.
"You don’t die from heroin detox. You don’t. You feel like you’re going to, but you don’t die." That's what Elaine was told when her son, Joe, was nearly kicked out of detox in 2012. Elaine called her insurer to inquire about the inpatient detox program before Joe checked himself in. She says her company told her it would be fine under her plan, but after only a few days the detox center called because her insurer had refused to pay.
We’ve agreed to call Elaine and, her husband, Doug by their middle names, and we’ll call their son “Joe.”
"They said he wasn’t gonna die. So, they didn’t have to pay. First of all, what a scam?! You’re not gonna die now!"
The couple agonized over the thought of Joe being put out. He was on the West Coast, and he was suffering complications from a severe lung condition.
"I remember I was still going through it. I did not want to move around. I wasn’t eating. I was throwing up," Joe recalls over the phone. He’s now serving time for credit card theft—a crime that he committed to get money for heroin.
"It looks like we might have to let you go. My parents were saying, well we’ll pay for it out of pocket, which would have been an outrageous amount of money," he says. Joe’s parents ended up paying nearly 10 thousand dollars out of pocket for his short stay in detox.
The specifics of this family’s case with the insurance company are unique, but the experience rings true for thousands of families in New York State. They sought treatment for a loved one only to be told it wasn’t covered by their insurance.
New York Attorney General, Eric Schneiderman, has gone after five of the state's largest insurers over the past year for illegally denying similar claims contrary to state and federal mental health parity laws. “And the settlements have required them to cover, drug abuse treatment and other behavioral health conditions, the same way they cover any other type of illness,” says Schneiderman.
Settlements with the AG’s office are re-enforced by state laws that went into effect in April. Lawmakers cracked down on insurance practices like “fail first” provisions-- that would only cover the cost of inpatient treatment after patients had failed at outpatient first.
“You have to fall off the wagon and get back to taking drugs or we’ve not going to give you a more advanced form of care. So, we’ve eliminated that and other requirements like that in our settlements. So, more New Yorkers are getting health care, getting the addiction treatment they need,” explains the State Attorney General.
That doesn’t mean everyone automatically ends up in an inpatient center. Today, state law requires insurers to look at multiple factors to determine what level of care is appropriate for each patient. Then all those factors are reviewed and approved by the New York State Office of Alcoholism and Substance Abuse Services--or OASAS.
Robert Kent is the General Counsel for OASAS. He says before lawmakers cracked down, health insurance denials pushed people into state funded programs.
“Effectively the funding we were providing to these programs, which is primarily intending to cover the care for people with no insurance, was on some level subsidizing the cost of people with insurance they were being denied access to the care,” says Kent.
Under the newest laws, a patient can stay in treatment while they appeal being denied coverage. For Doug and Elaine, back in 2012, that process took way too long.
"If I think about this, it’s dragging me down too far," says Elaine. Doug chimes in,"We’re already struggling with what’s going on with our son and worried about him surviving, and then having to fight with the insurance company."
But Kent from OASAS encourages New Yorkers go through with an appeal, “If you appeal there’s opportunity for us, for the state department of financial service to intervene and try to get decisions reversed.”
