Markley seeks review of insured drug-abuse treatment [Bristol Press]

Article as it appeared in the Bristol Press

Markley seeks review of insured drug-abuse treatment

Friday, January 11, 2013 10:33 PM EST
HARTFORD — Last April, state Sen. Joe Markley, R-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.

The findings are now public in a 37-page report.

∎ The state Department of Insurance does not sufficiently oversee behavioral health care coverage. It 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.

Markley and 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 caretakers,” said 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 time frame 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 legislators say the overall goal of improving insured youth’s access to appropriate treatment is critical.