Denial of Medical Benefits

[SZQ_Public]

Seeing as I'm furious at the moment, I hope I actually make sense here.

My husband is a drug addict. He is currently in detox. The facility he is at provides many programs for treatment.

My BC/BS of MASSACHUSETTS HMO policy summary clearly states under COVERED SERVICES - MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT . Under that it states Non-biologically-based mental conditions (including drug addiction and alcoholism) Inpatient admissions in a mental hospital or substance abuse treatment facility - up to 60 days in a calendar year.

The Hospital (which is part of HMOBLUE) offers the following:
Inpatient Rehabilitation
Individual counseling, group therapy, addiction education and self-help groups all contribute to patient progress toward sobriety, self-awareness and acceptance. A family education session is held weekly. The length of stay is from 6 to 14 days.


HMO BLUE uses a company called Merant Behavioral Care to handle mental health claims. This company will not approve coverage for my husband to use this program. They will pay for detox, that's it. They actually told me he could use the 60 days inpatient to go to detox 20 times. But they will not cover anything else.

I thought that this INPATIENT TREATMENT should be covered based on our plan summary. But Merant Behavioral Care says that this is NOT MEDICALLY NECESSARY. They say that the 60 days inpatient can be used for Detox only. In detox they are only treating the symptoms of withdrawal, not the addiction itself. So, in reality we do NOT have coverage for Substance Abuse Treatment Inpatient. To me this is a glarring case of false advertisment. I feel I was sold a service that I am not able to use.

I simply don't understand how on one hand they can tell us we have this benefit, then deny access to the benefit. I simply don't understand how on one hand they can say addiction is a medical condition, but it's not MEDICALLY NECESSARY to treat it? Detox does not treat addiction.

I'd like to make some kind of formal complaint to whatever state angency oversee insurance in Massachusetts. Does anyone know where I should begin?

 

[cbg]

Before you do that, check through your policy materials for any information about an appeals process. You will want to do that before you go to the state agency. It's always best to exhaust all internal options before going to outside agencies.

If you do end up going outside, it's the MA Insurance Division that you will want to speak with. The address I have is 470 Atlantic Avenue in Boston (sorry, I don't have the zip) but I don't know if that's the current address since I'm working from a 5 year old document. I also have a Consumer Help Line phone number - 517-521-7777 but again I don't know if that's current. It should help you get started though. Good luck.

 

[SZQ_Public]

thanks

Thanks,

I've requested a copy of the "subscriber certificate". I'm I correct to assume details of the appeals process will be contained in that?

I work on the street next to Atlantic Ave, maybe I'll walk over tomorrow at lunch and see if I can find some information.

CBG, am I dreaming or did I read/hear something recently that they are trying to enact laws to require insurance companies to treat mental health issues the same as medical issues?

I've written our Benefits administrator (with all the sorid details) looking for assistance, and she forwarded it to our VP of HR. Not sure I'm happy with that due to the nature of the problem, but maybe they'll help.

And my mother in law has already contacted our congressman (who's secretary happens to be her cousin). We might have a bed for him in a federally funded program, however he has to go to a homeless shelter first.

Isn't that crazy though.. We have insurance.. The insurance states coverage, but he has to go to a homeless shelter then into a program paid for by the government?

Thanks for your response. I can always could on you to have real knowledge and answers to my questions! thanks

 

[cbg]

The Mental Health Parity Law, which was actually enacted several years ago (I can't tell you how many but I was still working for the insurance company and I left them in 1998) was supposed to ensure that mental health was treated the same as other illnesses but it had a number of holes in it that did not become apparent until it had been in effect for a while. I vaguely remember seeing something recently that they were trying to patch the holes in it so I imagine that's what you read. Since I'm no longer in the insurance business I don't keep up with that sort of change unless it appears that it's going to affect one or more of my employees.

When I was working for the insurance carrier (it was not Blue Cross but it was a national carrier) mental health claims were always difficult because so often they were sub-contracted, and we didn't always have control over the sub-contracter's policies. I remember one instance where a particular facility was in-network for us (they did other things besides mental health) and out of network for the mental health sub-contractor - boy, was that a mess!

Good luck to you. Post back and let us know how it comes out.

 

[SZQ_Public]

My benefits administrator and HR Rep just had a conference call with Merant Behavior Care. They were told that our plan doesn't cover inpatient rehab, only outpatient rehab.

After the medical detox, everything is considered rehab. It seems that the insurance company only cover what MANADATED by state law.

I wonder if the loopholes in the Mental Health Parity Laws is what allows this. Years ago this would have been covered.

I'm going to tell my husband he needs to take a different angle. He should stress the DEPRESSION side of his condition. Maybe even threaten suidicide. If they recommended an inpatient stay for that it would be covered.

 

[cbg]

It's worth a try.