NYAPRS Note: Ensuring continued access to treatment during an appeals process should be a fundamental right of individuals facing debilitating addiction or crisis. However, the impacts of such a rule weigh heavily on payers, who are newly responsible for behavioral health parity and are expected to prioritize that line of their business. The concerns raised by the insurers are valid: how can we continue to serve individuals in acute need, with no real indication of how their needs could better be served, or whether the treatment provided is of good value? This question is one that the mental health and substance abuse fields are grappling with, as demands for community services rise and payers across the spectrum pay more attention to quality and outcomes.
Insurers Cope with Heroin Bill Pact
Crain’s Health Pulse; 6/19/2014
The package of bills announced yesterday to address heroin addiction includes many provisions that affect commercial insurers in the state. Lawmakers announced the deal on drug treatment and policing after Gov. Andrew Cuomo made it clear he wanted a deal before the end of session.
As Pulse reported last week, the New York Health Plan Association had concerns about the new mandates presented by an earlier version of the proposed legislation. In the current form, the bill, online here, gives patients access to an expedited appeals process; they will have no interruption in treatment while the appeals process is underway.
Insurers must use evidence-based and peer-reviewed clinical review criteria approved by the state Office of Alcoholism and Substance Abuse Services when making coverage decisions about the medical necessity of treatment and the appropriate level of treatment. Those decisions must be made by specialists in behavioral health and substance use. The new bills also focus on designing a new model of care that would divert patients who do not need hospitalization to outpatient treatment.
Providers seeking an extension of services must make a request for a review 24 hours before the patient’s discharge; plans are required to make a decision within 24 hours of receiving the request. When there is an adverse determination, the patient or provider can request an expedited external appeal, which must be made within 72 hours—as is the case under existing law—but now coverage cannot be denied pending the determination of the appeals.
After today’s agreement, HPA said it was still concerned that the legislation “requires plans to pay for services even when an independent review determines the treatment was not medically necessary, which data from New York’s external appeals law show happens in four out of five cases.”
Where treatment takes place has sometimes been subjective, resulting in higher costs for insurers. Parents of drug abusers tend to want their children hospitalized for treatment, because they know the child or young adult can’t access drugs and will be in a safe setting. If the patient is undergoing outpatient treatment, it is more difficult for parents to control such factors.
“The potential of paying for unwarranted and potentially inappropriate care in nearly 80% of cases is troubling,” HPA President Paul Macielak said in a statement.
The new legislation also creates a work group that Mr. Macielak said should focus on developing standards and performance measures for substance-abuse disorder treatment services. “Treatment programs and facilities are not all equal, and the lack of information today in these areas makes it difficult for plans, patients and families to evaluate treatment,” he said.