Why are treatment decisions being made by insurance companies rather than doctors?

Understanding Parity Laws for Mental Health and Addiction Treatment

The high cost of treatment for mental health and substance abuse disorders has traditionally blocked many people from receiving treatment that can make their lives healthier and more productive. Even people with insurance coverage have frequently been denied care because until recently, mental health conditions have been covered differently than medical conditions.

Merriam-Webster defines parity as “the quality or state of being equal of equivalent.” This is a simple definition, but the meaning becomes muddy when it comes to deciphering the Mental Health Parity and Addiction Law (MPHAEA).

The Parity Law, which was approved in 2008 and became effective in 2010, applies to insurance providers and group health plans that provide coverage for both medical and surgical benefits and mental health/addiction. The act stipulates that benefits for mental health and substance abuse disorders must be no less favorable than medical or surgical benefits, including co-pays, deductibles, treatment limitations, and annual and lifetime dollar limits.

The Parity law places heavy emphasis on the words, “stipulates,” “restrictive,” and “predominant,” stating that health plans may not apply financial requirements or treatment limitations to mental health/substance abuse benefits in any classification that is more restrictive than the predominant financial requirements or treatment limitations imposed on substantially all of the medical or surgical benefits offered in that same classification.

This means, for example, that an insurance plan that allows an unlimited number of visits to a family physician can’t limit psychiatric visits to a set number of appointments.

A number of exceptions make the parity law even more complicated.  For example, the requirements do not apply to small, private employers with no more than 50 employees or to non-federal governmental insurance plans with no more than 100 employees. There are other exceptions, including those pertaining to certain state and local health plans, Medicare, and most plans purchased outside the Health Insurance Marketplace.

It’s also important to understand that employers who do not already offer mental health or substance use coverage are not required to offer that coverage. Although MPHAEA is a federal law, some states require more coverage for mental health and substance abuse.  In this case, state law trumps federal law. Insurance plans are required to make specific requirements available upon request. Reason for denials must also be provided.  If you think your insurance provider has unfairly denied coverage for mental health or substance abuse treatment, contact your insurance provider’s customer service department. If you still have concerns, contact the Insurance Commissioner in your state for more information. If necessary, you can appeal your insurance company’s decision.

Does all of this sound very complicated? That is exactly how insurance companies want it to be. The less we understand, the more insurance companies are able to dictate how and what they treat.   There has been a trend over the past few years for even general medical disorders to be treated based on decision not made by medical professionals.  Insurance companies determine what kind of treatments they “allow” and what medicines they “allow”, even what surgeries they “allow”.  Their decisions are reviewed by hired guns (physicians) paid to support their policies. They have vast leeway in making these determinations based on their own in-house determinations, regardless of what the best medical evidence (research) has found.  This practice has made the practice of medicine seem to be done by insurance company decisions based on predetermined allowances rather than best medical practice.

Frustrating.  Now, despite parity law, insurance companies continue to dictate treatment for addiction in the same way.  There are very stringent criteria published by the American Society of Addiction Medicine that make determinations based on best evidence what the best kind of treatment a person needs, yet these are ignored by most insurance companies base on their own in house criteria.  That is why more and more limitations continue to be placed on treatments they “allow”.  Many treatment centers exist, actually a majority of them, willing to offer substandard treatment that insurance “recommends” and treat large numbers of people.  They make up for what insurance will not pay for by treating mass quantities at lower rates.  Why do we accept best treatment decisions to continue to be made by insurance company policies rather than what medical professionals have determined?  

Please, please, please report denials of proper care to your insurance commissioner.  There have been some large class-action law suits awarded against insurance companies that break the law in some states, but this can only happen if we report abuses.   Addiction is related to one in four deaths in this country, and is the number one cause of accidental deaths, yet treatment availability and practices resemble the “wild wild west.”  Get involved.  Make sure there is an ASAM/ABAM doctor actively involved in treatment of this medical disease, not just present for the intake and discharge.  Ask how long treatment will be and why.  Ask a professional if inpatient versus outpatient will provide the best results for this fatal disease. Look for an answer other than “that is all that is allowed,” and then we can approach parity. 

Credit:
_{https://www.nami.org/Find-Support/Living-with-a-Mental-Health-Condition/Understanding-Health-Insurance/What-is-Mental-Health-Parity
https://parityispersonal.orghttps://s3.amazonaws.com/HMP/hmp_ln/imported/final%20detailed%20summary.pdf
https://www.dol.gov/ebsa/newsroom/fsmhpaea.html
benoiction-Equity-Act-Final-Rules-Limited-Enforcement-Options-Dont-Overcome-Unequal-Treatment.pdf}