Be in the know of issues that effect families raising children with special needs.
A LandMark case against UNIted behavioral health via mental health & autism insurance project
A federal court in Northern California ruled that United Behavioral Health (UBH) unlawfully denied the claims of some 50,000 patients who needed treatment for mental health and substance use disorder. The judge found that UBH used their own deeply flawed, internal guidelines as the basis for denying important treatment to patients. The plan's guidelines were created in part to deny more lengthy and expensive coverage for outpatient, intensive outpatient and residential treatment for mental health disorders.
A significant result of the court's ruling is the identification of evidence-based, "generally accepted standards of care". The guidelines are based on the research and guidance of clinical specialty organizations like the American Society of Addiction Medicine (ASAM - include link) as well as the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS). The court established that health plans should not "create or buy" guidelines when there are already well-established clinical criteria from clinical specialty organizations. The internal UBH guidelines were, according to the judge, "unreasonable and an abuse of discretion."
The court found that UBH's medical-necessity guidelines inappropriately limited coverage based solely on acute symptoms. According to the judge, "UBH knowingly and purposefully drafted its Guidelines to limit coverage" and that effective treatment should include not just addressing current symptoms but also the underlying condition.
Significantly, the court noted that effective treatment of mental health and substance use disorders includes aiming to prevent relapse or deterioration and to maintain a patients level of functioning. UBH guidelines did not adhere to this standard because they required a finding that treatment should cause a patient to improve within "a reasonable amount of time", thereby reducing treatment to a reduction or control of acute symptoms only.
In addition to establishing clinical guidelines for treatment, the court found that UBH violated the federal Mental Health Addiction Equity Act, which requires large group health plans that offer mental health or substance abuse disorder to offer similar benefits to mental health and substance us disorder patients the same level of coverage that they do on medical/surgical benefits.
UBH used their in-house guidelines as a way to circumvent the requirements of the act to keep their costs down. The judge reminded UBH that chronic and co-morbid condition should be treated even when those conditions persist or need extended levels of care (much as a health plan would treat a patient with a chronic health condition like diabetes.)
What the Ruling Means for You
In advocating for appropriate treatment of mental health and substance use disorder, it’s essential to familiarize yourself with the generally accepted standards of care. Often guidelines developed by insurance companies are not in compliance with these standards. In fact, the judge found that UBH was not the only health plan to develop faulty guidelines in order to limit care.
In MHAIP’s work writing appeals for for people denied residential treatment, we frequently see reasons like, “You do not meet our standards of medically necessary treatment. You are not actively homicidal, suicidal, or currently hallucinating. Therefore, you do not need 24/7 care at a residential treatment center. Your care could be treated at the outpatient level.” This type of denial will no longer be acceptable and reviewers will need to look at the bigger picture, including providing enough time and treatment so that clients can address the underlying issue which contributed to the crisis and develop effective coping skills. Reviewers will also need to follow the standards established in this ruling that treatment should maintain the patients functioning going forward and prevent deterioration - no simply treat “acute” symptoms the necessitated treatment to begin with.
CHALLENGES IN GETTING AUTISM SERVICES
The number of children diagnosed with Autism Spectrum Disorder has increased dramatically in the last two decades. Even when diagnosed at a young age, many families are confronted with lengthy wait times to access treatment like speech therapy, occupational therapy or behavioral interventions, or simply to get a formal diagnosis. Too often, parents are told by their health plan that they simply don't have the providers or agencies to treat their child with ASD. In some case, health plans flat out claim that they don't have providers in network as an excuse not to provide appropriate treatment. To counter these wait times it's important to know your rights and to have a strategy for dealing with time obstacles to your child's care.
Tips for getting care sooner:
Keep track of the dates you made the request or received a referral for treatment. Most fully-funded health plan's are required to abide by certain timelines.
Be Assertive - this includes calling frequently and asking about the status of your child's referral.
Ask to be put on a cancellation list. For example, if you are waiting for an initial intake appointment (often the most time-consuming part of the process for providers), offer to be flexible about how much notice you need to come in for an appointment, if possible.
Keep copies of all correspondence between you and your health plan.
Write down all phone calls and dates. Request reference numbers for phone calls. Use your health plan's online chat feature and print out the transcript.
Know your rights and file internal and external complaints (see below).
KNOW YOUR RIGHTS
Timely Access to Care
Check your state health insurance regulator for guidelines they recommend for wait times for appointment availability. For example, in the state of California, the Department of Managed Health Care (DMHC) has developed standards for appointment availability for mental health and specialty care appointments. They stipulate that these types of appointments should be offered within 10 to 15 days. In addition, you should be able to locate these guidelines within your benefits documentation (often called Evidence of Coverage or EOC).
In 2015, the Insurance Commissioner of California issued emergency regulation that addressed the issue of insufficient providers limiting patient’s access to care. They require health plans to include an adequate number of providers in their network, including those who provide mental health and behavioral health care. Significantly, the Commissioner directed plans to “make arrangements to provide out-of-network care at in-network prices when there are insufficient in-network care providers.” If you live in California and have a fully-funded plan, you can either cite these guidelines in your internal complaint or file a complaint with the Department of Managed Health Care to get your health plan to offer an out-of-network provider to you.
TIP: If you do not live in California or your fully-funded plan is regulated in another state, find the state regulator at www.ncsl.org and and find out if your plan’s regulator has established guidelines when plan’s do not have sufficient in-network providers.
File a Complaint with Your Health Plan
Keep track of the amount of time that has elapsed from your request for autism treatment, or a physician’s referral for treatment, and the actual time you have had to wait. If it exceeds the plans guidelines, file an internal complaint with your health plan. If the plan told you they do not have enough providers, make note of that and the relevant state regulator’s requirements (as in the case of California)The internal process can take 30 days.
File a Complaint with the Plan's Regulator
If you are not offered timely treatment after the internal complaint process, you can file an external complaint with the regulator of your health plan. Your health plan should provide you with the information about how to file an external complaint. If they do not, you can locate this information by navigating to your state’s regulator.
Include in your external complaint the list of dates you contacted the plan, their response(s) and how long you have waited. Be sure to mention the reasons your health plan gave for delaying treatment, including whether they have sufficient in-network providers.
TIP: Check where your plan is located. In some cases your plan may be located in, and regulated by, a different state. Read through your coverage documentation for this information.
CASES WE HAVE WON
Win in external review: After having been denied twice by BCBS of Texas, we won 6 ½ additional weeks of mental health residential treatment for an 18-year-old young Texas man diagnosed with schizoaffective disorder, bipolar type and a severe substance abuse disorder, in addition to trauma and developmental delays. MHAIP documented the 19 documented incidents of unsafe or aggressive behavior that met the criteria for mental health residential treatment to counter BCBS of Texas’ claim that the young man “could be treated safely and effectively in a less restrictive level of care such as Substance Abuse Partial Hospitalization/Day Treatment (PHP).” Because we won this in the external review process, it allowed us to then pursue residential treatment level of care for the final potion of this young man’s stay at a treatment center.
Win in external review: After months and months of stalling and delay tactics by Aetna and Beacon, we successfully won seven months of residential treatment level of care for an 18-year-old young woman from Kentucky diagnosed with oppositional/problematic behavior, mood and anxiety disorders, alcohol and substance abuse issues and trauma from sexual assault. Aetna and Beacon attempted to deny coverage for her stay at the residential treatment facility by claiming the provider was “not eligible to receive reimbursement” and that ““the member’s plan excludes this service” and then finally that the care was “not medically necessary.” MHAIP documented the 23 unsafe, inappropriate or aggressive incidents that met the criteria for mental health residential treatment as well as the slow progress she was making in the program, which convinced the external reviewer that the care was medically necessary. The external reviewer also affirmed that residential treatment was a covered benefit of the medical plan.
Overturn through Employer Involvement: MHAIP assisted the family of an 18 year-old young man from Wisconsin with attachment and self-harm issues obtain two months of residential mental health treatment. When the employer switched the plan to Anthem, they denied coverage. MHAIP wrote an appeal, but it was denied. We encouraged the family to take our appeal to the benefits manager at work. Says mom Paula
“A final tip I want to leave for other parents – read the ENTIRE insurance policy! I found a single sentence on page 105 of a 154 page document that states:
‘The employer can In certain circumstances, for purposes of overall cost savings or efficiency, in its discretion, offer Benefits for services that would otherwise not be Covered Health Services.’
We went to the Benefit Coordinator at my husband’s employer and she was a champion advocate for us! Thank you for helping us with this marathon! We learned that it up to us to demand services! We knew we had to fight for what was right and equitable even though the insurance companies made every step as inconvenient and prolonged as possible. MHAIP made all the difference in our attitude and our outcome!”
Win of an Out Of Network Exception on Appeal: Advised the father of an 18 year old girl from Maryland diagnosed with anxiety, depression, substance abuse and trauma disorders on how to negotiate an out-of-network exception with United Health Care to get his daughter's stay at a residential treatment center covered. United Health Care insurance company denied mental health residential treatment level of care twice, but when the United Health Care insurance representative read MHAIP's appeal about the girl's struggles and her need for residential treatment as well as the impact of the girl's behavior on her family, she agreed to approve an out of network exception.
Won 69 Days of of Coverage for Wilderness for CA Family: We won 69 days of coverage of a wilderness program in Utah for substance abuse for a 19 year old man from Alameda County, CA. Health Net initially failed to process the claims, then instructed us to obtain retroactive authorization, then would not allow us to retroactively authorize services, though instructions to do this were provided in the plan manual. We filed a written complaint to the plan, which they failed to respond to. When we followed up by phone, we learned that services were found to be medically necessary, but because they failed to pay the claims, we sought the assistance of the California Department of Insurance (CDI). After conducting a thorough investigation, CDI required that Health Net pay according to the terms of the contract.
Recovery of 87 Day Wilderness Stay: We recovered an 87 day stay in a Wilderness program in Idaho for the family of an Idaho teen suffering from depression and anxiety. The plan paid according to the terms of the contract after many phone calls and claim resubmissions.
Follow up to a win from the last newsletter: In our last newsletter, we reported winning over six months of residential therapy for a young woman from Colorado suffering from depression and eating disorders. We went back and successfully appealed a "timely filing" denial for the first six months of her stay. After many months of follow-up, we prevailed, as there was a clause in the contract that indicated if you were “legally incapacitated” the period for submission could be extended.
Win in Independent Medical Review: 15 hours of direct, weekly ABA treatment for a 16 year old male with ASD was denied by Anthem Blue Cross and reduced to 10 hours. The Department of Managed Health Care (DMHC) referred to the case for an Independent Medical Review (IMR). The reviewer found that 15 hours of direct, weekly ABA were medically necessary to treat the symptoms of his autism including adaptive skills, communication difficulties, safety awareness and executive function skills, among others. The review cited evidence-based guidelines developed by professional, clinical organizations.
Win in Independent Medical Review: Intensive outpatient treatment for a 3 year old child with oppositional behavior, aggression and anxiety was denied. Cigna Health denied both reimbursement for treatment beyond an initial 10 day authorization as well as denying prospective authorization for ongoing treatment. The California Department of Insurance (CDI) sent the case for an Independent Medical Review. The reviewer found that intensive outpatient treatment for a period of 6 months was medically necessary for the child, citing the Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines developed by the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists.
The Full Ruling can be read HERE