Insured often wrestle with insurers to get longer rehab care

Addiction treatment runs primarily on insurance and tax dollars.

The state Department of Public Health funds programs like ServiceNet’s three Greenfield and Orange residential treatment homes — where patients pay what they can, often donating food stamp benefits to feed the group — and it backs The RECOVER Project in Greenfield and distribution of the overdose antidote naloxone/Narcan.

Thanks to a 2000 federal law and a 2008 state version, insurers are required to treat addiction like any other disease, but advocates say law and reality don’t always mesh.

Insurance typically covers short stays of a week or less in detox and Suboxone or Methadone treatment — but may balk at intermediate and long-term care.

And even detox coverage might take more of a fight than a person in a brief moment of clarity, or their frustrated family members, might be able to put up.

Maryanne Frangules, executive director of the advocacy group Massachusetts Organization for Addiction Recovery, has been fighting the insurance situation for years. She feels the current laws mandating insurance coverage are imperfect.

The latest ray of hope is at the federal level.

“Right now we want to have hope — the Affordable Care Act is supposed to offer more availability ... but something can be on paper and not be enforced,” Frangules said. “We need as people who vote to really demand our rights. Nobody should have to fight to be able to get the help that they need.”

MassHealth, the state’s umbrella for medicaid and a child insurance program, covers addiction treatment similarly to private insurers, or through them. The program for low-income residents either covers health costs directly or pays for all or part of a patient’s private insurance.

The coverage list includes acute inpatient care, long-term chemical maintenance, and long-term therapy and special programs for pregnant women. Long-term residential programs are not listed. In Franklin County, these are funded almost exclusively by the Department of Public Health, with patients paying rent if they can afford to.

The state Division of Insurance is responsible for enforcing the addiction recovery insurance payment related laws.

A pattern of a company refusing claims may trigger an investigation, after which the Commissioner of Insurance may order a corrective action plan, a fine of $10,000 or less for each violation, and may suspend or revoke a carrier’s accreditation, license or certificate of authority.

The office did not respond to questions including how often these penalties have been used, but did respond via email to earlier questions.

Massachusetts health insurers are required to provide benefits for mental and behavioral health care at the same level as other medical care. Federal rules additionally prohibit insurers from implementing special application procedures for behavioral coverage, according to statements attributed to Commissioner of Insurance Joseph G. Murphy.

What treatment is and is not medically necessary, and therefore eligible for coverage, is based on medical necessity criteria commissioned by the insurer, from the company’s medical director, with input from providers.

“Each of the Massachusetts health plans has a medical director who is responsible for the development and application of the medical necessity criteria used by that health plan,” Murphy wrote.

Long-term care may be covered. “The health carrier will provide benefits for long-term inpatient care where medically necessary,” Murphy wrote.

A local father, Greg (not his real name) who contributed to this series, says he believes that once his son moved from pills to heroin, the word “heroin” went a long way to proving medical need, and once in a program the program staff were better equipped than he was to deal with the insurance provider.

“People really need to have an advocate behind them,” Frangules said. “But for a lot of people there is a vacuum out there. Usually you feel like it’s only happening to you and what can you do?”



Series at a glance: Pushing Back

Friday, May 2, 2014

A year ago, we reported that addiction to heroin and its painkiller cousins was ravaging lives in Franklin County.  Now, this new six-day series asks “what can we do?” ... to reclaim those ruined lives and beat back the threat of chemical enslavement. … 0

There are no comments yet. Be the first!
Post a Comment

You must be registered to comment on stories. Click here to register.