My husband’s insurance… would not cover a Betty Ford-type rehab center… [coverage] limits him to something like 8 Sessions 8/4 & 9/4

-Mental Health Services

My husband has, after many years, agreed to get help for his drinking. We were surprised to learn that his health insurance benefits would not cover a Betty Ford-type rehab center, and would only provide weekly outpatient counseling. We were further dismayed (and angered) to find, despite Massachusetts’ “mental health parity” law, that his insurance limits him to something like 8 sessions. That seems like so little for such a big problem, when in the past he’s tried to stop drinking many times on his own and failed. Does it make sense to you?

PART ONE] Concerns about the limits of managed care, particularly related to gaining access to treatment, have been brought to our attention a number of times recently, so we will use this opportunity to piggyback onto last month’s column that addressed the difficulty of finding an available therapist. Prior to managed care (which hit the scene abruptly in the mid-to-late 1980’s), it was common for individuals with alcohol or drug dependence to spend about a month in an inpatient rehab. Most of these, like the Betty Ford Center, were based on the “Minnesota model” of detox followed by weeks of individual and group therapy (along with such ancillary activities as family therapy, exercise, nutritional counseling, meditation, use of AA, etc.) designed to reduce denial, foster acceptance of alcoholism/addiction as an illness and provide an initial grounding in sober living. Almost all of the facilities of that type in New England no longer exist. Individuals who still enter such programs (generally in other parts of the country) usually do so on a self-pay basis, at a cost in the range of a year’s college tuition. The rare health plans that do cover such facilities often apply to members of labor unions.

In Massachusetts today, health insurance will generally cover detoxification only if the individual has true withdrawal symptoms (such as “the shakes”). In those cases, a typical length of stay might be 4 days – just until the acute withdrawal symptoms abate and the patient’s vital signs return normal. Some plans may also cover a period (often two weeks) of “partial hospital” (day) treatment, in which the patient lives at home but spends about 6 hours a day attending group therapy, while receiving individual case management and psychiatric oversight. That’s as close as most patients are going to come to “rehab” when insurance is picking up the tab. Following partial hospital treatment, or instead (if it isn’t covered), insurance usually provides limited coverage of “outpatient” care, which usually means one session per week (individual and/or group therapy). As to the limited number of sessions that your HMO will authorize, that’s a large enough topic to wait for our next column. Meantime, let us remind you that LCL’s staff deal with the insurance morass all the time (though our own services require no payment), and are available to help you navigate.
[PART TWO] Managed care’s raison d’être is to save money, reduce skyrocketing health insurance premiums (though it does not seem to have had this effect), and in most cases maximize profits. Cuts in services have been more dramatic in mental health/substance abuse than most medical services. Though the cost managers have been a bit kinder to outpatient treatment than to inpatient, they have nevertheless erected a number of gateways and obstacles to try to contain costs.

It is true that the Massachusetts Mental Health Parity Law of 2000 mandates that the limits of coverage for mental health conditions cannot differ from that for physical conditions. However, the law contains some very significant restrictions:

§It only applies with full force to so-called “biologically-based” mental health conditions, including major mood and psychotic disorders as well as certain anxiety disorders. ¨

§For less severe mental health disorders, insurers must cover up to 24 sessions per year, and few if any exceed that “minimum maximum.” ¨

§Alcohol and substance abuse disorders, though they would appear to fit within both the “biological” and “mental health” categories, are excluded from both. For these disorders, the mandate is only for $500 worth of services per year (which might come out to around 8 sessions at managed-care-discounted rates). So if one is both alcoholic and depressed, for example, there may be significantly more coverage (via the depression diagnosis) than there would be for alcoholism alone. ¨

§If your employer is “self-insured,” meaning that health claims are paid with the employer’s own funds (i.e., in which the insurance company merely administers the process), the Parity Law does not apply at all, and the plan can impose whatever limits the employer desires.

Regardless of the supposed annual maximum, however, managed care plans need not cover these services beyond the point that they consider “medically necessary.” When the patient sees an “in-network” provider (mandated by HMOs, and encouraged via financial incentives in PPO and POS plans), the managed care company will usually authorize an initial 8 to 12 sessions. If further treatment is desired, the therapist must complete and submit (just before the authorized sessions run out) a detailed request form disclosing much more about the patient’s problems and progress. Typically, a few more sessions will be authorized per request, followed by the need to submit more forms and client information. Obviously, this system builds in incentives for the clinician and/or patient to lean toward a brief course of treatment. It is certainly not designed to minimize relapse potential, and tends to ignore the multiple medical, legal, commercial and family consequences of active addictive behavior. Since LCL’s staff is familiar with “how the game is played,” we may be able, in various ways, to assist when any lawyer, judge, or law student bumps up against these roadblocks to adequate coverage.

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