Hartford, CT - Last April, Senator Joe Markley (Southington) urged his fellow members of the Program Review Committee to investigate a disturbing trend: the failure of insured adolescents to receive necessary and effective treatment for prescription drug abuse addiction.
"Representative Rob Sampson and I were approached by parents in Southington and Wolcott who--despite private health coverage--had struggled to secure proper treatment for their children," said Sen. Markley. "In response to our concern, the committee directed staff to look into barriers to receiving substance abuse treatment, and to find out if the state's coordination with families was effective."
The findings are now public in a 37 page report, which uncovered some disturbing facts, including:
- The Connecticut Insurance Department (CID) does not sufficiently oversee behavioral health care coverage. CID does not check that fully-insured plans (the limits of its jurisdiction) comply with all aspects of the federal parity laws.
- It also does not use data received from the plans to detect and resolve potential problems in how plans determine, through the utilization review process, whether requested behavioral health care is covered in an individual situation.
- The state's Medicaid program offers a slightly wider range of substance use treatment options and has higher coverage approval rates, compared to fully-insured commercial plans. The fully-insured plans' approval rate for residential treatment--which many parents feel is the most effective approach--is the lowest among the levels of care.
- Fully-insured plans are not required to make initial coverage decisions using practitioners and criteria that would be the most appropriate. The practitioner does not need special expertise or to use the manual widely agreed to represent consensus on the necessary level of care and duration of treatment for a particular client.
- There are appeals processes available, but most coverage denials are not appealed. Denial notices are not required to indicate that state agency assistance with appeals is free or to specify what types of documentation could help an appeal succeed.
"These findings show that insurance companies often lack clear standards for coverage, don't have qualified practitioners making decisions, and disallow the most appropriate treatment for children who are fully-insured and should receive the care their parents are paying for," said Markley.
"There is also a lack of communication when it comes to informing parents that they can appeal a denial for free and receive help from the state. These families are suffering; when they are denied help, they should also be informed of their options," said Rep. Sampson.
Sen. Markley and Rep. Sampson say having some more clearly defined standards would benefit insurers as well. "We need to enable these companies to make responsible changes. It is about open conversation with insurers, families and care takers," said Rep. Sampson.
Recommendations of the Program Review committee include:
1. Improve CID over sight, by instituting a new check of plan compliance with the federal parity law and requiring data be used to actively monitor utilization review results.
2. Require substance use treatment coverage decisions be made more quickly and appropriately, by having stricter requirements about the decision timeframe and methods.
3. Make the appeals process more user-friendly, by being explicit about the availability of state assistance and how to support an appeal.
Both Sen. Markley and Rep. Sampson say the overall goal of improving insured youth's access to appropriate treatment is critical. In Connecticut, about 8% of youth ages 12-17 and 24% of those ages 18-25 have met the clinical criteria for abuse or dependence on alcohol or an illicit drug with in the past year, according to a National Survey on Drug Use and Health (NSDUH). Only 10% of those afflicted receive treatment.
As the PRI report suggests, substance use has tremendous costs to society, families, and individuals, and it often results in cost-shifting from the private to public sector.
"Changing the way insurance companies decide who gets what care in a thoughtful and responsible way will not only help society as a whole, but it will give these kids a chance at getting better and give these families some peace in their ongoing struggle," Rep. Sampson said.
"Prescription drug abuse is a national problem, by no means confined to our young people," said Sen. Markley. "Recent statistics indicate that drug overdoses now kill more Americans than traffic accidents--a sudden and alarming development. I will try to find a way that we can address this plague as a state; this report is a first step in that effort."
The Program Review Committee chairs will be in charge of raising these concepts in a bill during the 2013 Legislative session. Both Markley and Sampson are hopeful the bill will go onto the Public Health and Insurance Committees for review ultimately making its way to through the General Assembly and onto the Governor's desk for approval.