Mental health parity may finally become a reality

The Wellstone Act could bring better health care to millions of Americans

"This is like reliving a nightmare," says Kim, who asked that only her first name be used.

Inside the binder is the arsenal of files Kim built up over a year as she fought her insurance company, HealthPartners, to cover her son's treatment for chronic addiction.

Kim is an accountant; she deals with bureaucracy professionally. But in January 2010, when HealthPartners denied coverage for the second half of her son's 60-day treatment program, Kim found herself in unfamiliar territory.

By that point, her 22-year-old son had been in and out of rehab programs since he was 15. During his senior year of high school, his parents caught him with meth. In 2007 he tried a program at Hazelden. Nothing worked.

This new program seemed to be taking root when HealthPartners said that it would cover only the first 30 days. The second half was not, the company wrote, "medically necessary."

"You've got a child that has been so sick and so close to death, and you finally get them into treatment and they're doing okay, and then all of a sudden the insurance company says, 'We're not going to pay,'" Kim says. "So then as a parent you have a choice."

Kim and her husband decided to pay $12,000 out of pocket to keep their son in treatment. Between that money up front and their steep $10,000 deductible, HealthPartners covered only a tiny fraction of the $24,000 program.

The next month — after her son had completed treatment, entered a halfway house, and begun reconstructing his life — Kim woke up ready to act. She wrote the HealthPartners Board of Directors a letter saying that they should pay her claim, but again got denied.

In the denial, HealthPartners cited the American Society of Addiction Medicine criteria as their standards. But when Kim asked for more information, she got a letter saying that the company didn't have to give her any explanation.

"How am I supposed to prepare an appeal if I don't know what the standards are?" Kim remembers asking.

So she researched the guidelines herself, found the official manual, and called up its editor. He was the first person who could give her directions on how to proceed.

For the next four months, Kim pulled together all of her son's medical records from his five years of treatments, and paired them with the criteria in the ASAM manual. She found that HealthPartners' stated guidebook called for treating addictions like her son's with a program similar to the one he had been in.

When she was done, Kim sent in her nearly book-length packet to HealthPartners for her second appeal. She was denied the same day.

Kim ultimately won, but not before making her case in person at the HealthPartners Board of Appeals. She guesses that, by that point, she had devoted more than 200 hours over seven months to the process.

"Even in a state like Minnesota, which is one of the better states, Kim had to go through a million hoops," explains Nell Hurley of the Minnesota Recovery Connection. "Her son only got the care he needed because she was persistent and very well-equipped."

In a statement to City Pages, HealthPartners noted its support for the Wellstone Act, and cited efforts like its brand-new $36 million, 100-bed mental health facility at Regions Hospital as proof of its commitment.

Kim's son is now two years sober and a mechanical engineering student.

"If I hadn't had the skill, the time, the money to get for my son the treatment he was legally entitled to," Kim says, "I don't think he would be here today. I don't see how other people could do it. I think the insurance company expected it to be confusing and time-consuming enough to make us give up."


After Katie Bird sued UBH, they settled for a sum she can't disclose. But, she says, "I feel like we won."

Bird spent three months living at the Emily Program, treatment that totaled around $157,500 according to court documents. That doesn't include the cost of her two hospitalizations and the Intensive Day Program treatment she was in while fighting with UBH over whether she could enter residential care.

That's a heavy tab. But to Bird's lawyer, some of it could have been avoided by giving Bird the treatment she needed earlier.

"She was spending all of this time on the inappropriate level of care, and she could have spent that time in residential and probably avoided all of it," says Wrobel. "At the end of the day, they're trying to save money but it's probably more costly."

Bird also points to the unquantifiable victories, like the fact that she is now able to be a mom to her two children. "I never, ever, ever thought I would be able to live like I am now," Bird says.

To Dave Wellstone, experiences like hers are the reason to keep fighting.

"Everyone knows someone who is impacted by mental health," he says. "Those are the stories that keep you going. You don't have to look too far."

Opinions vary on when Washington might come out with some final regulations. Ramstad is on the optimistic end of the spectrum and hopes it can be accomplished in the coming weeks. Sue Abderholden hopes for next fall at the latest.

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10 comments
land0218
land0218

I worked for Cigna for five years and saw all of this unfold on a daily basis.  Sometimes it was blatant, and other times it was a bit more confusing.  I completely agree that if a person has benefits and has not used them, then regardless of the level of care, especially if it is being recommended by an M.D., that person should be allowed to receive care for their issues.  If they have no insurance, that's another complicated matter.  

The one hang up, and I think this article pointed it out, is that when a person does not get the care needed, and they end up getting tossed around the system, getting "lower levels" of care, such as outpatient or intensive outpatient to save on cost, when the reality of it is that if they were simply allowed to receive a residential program from the beginning, maybe the years of hassle, other failed treatments, and expense could have been avoided.  Unfortunately, once you've maxed your benefits for the calendar year, forget it, your done!  And there is an abundance of elephant dung sized health care plans to see to it that you exhaust your benefits as fast as possible.  In other words, if your benefits renew calendar year starting in January, and your actively seeking help for you mental health or substance abuse  issues, you could conceivably max out by February, and spend the rest of the year without help or treatment, unless you keep paying out of pocket.  

This issue could easily be a 900 volume tome, and I could ramble on at great length, but I guess from the insurance perspective, they only do what is necessary to keep a human being alive and functioning (feed themselves, dress themselves, bathe)  at the bare minimum of expense, which I think is where the term "medical necessity" stems from.  And why the insurance companies have the power to determine this over the M.D. treating the patient, I will never know.  Mental health and substance abuse are not as easy a fix as mending a broken arm, or stitching up a wounded knee, they're much more long term, and progress can move very slowly.  If I may be allowed to be a bit of a hippie about it, my hope is that if we the human species have any hope of progressing further, and sustaining life on this planet, the cost, no matter what ridiculous financial figures they produce, would ultimately become a true non-issue.

...bit of rant I know, sorry, just wanted to get that out and add it to the discussion.  Thanks. 

markmywordz
markmywordz

There is an important technicality here that needs to be better explained.  Minnesota already has a mental health parity law so Minnesotans who buy health coverage from anything other than large employers were already covered by the parity law.

This new law was only for large employers who are exempt from all state mandates like mental health parity.  And, most important for these large employers, they don't actually buy insurance.  They are self insured so it isn't actually the insurance company issuing the denial, it's a third party administrator (many times an insurer who is running a TPA) that is implementing the coverages laid out by the employer.

So the complaints about the insurers not paying, should be more appropriately leveled at the employers who were not willing to pay.

Finally, there is a very important reason for claims denials.  It's to keep costs low.  While the call for better coverage is certainly worthy and nobody can deny it is very much needed, the problem is that it is extraordinarily expensive and most of these people want the treatment, but they want somebody else to pay for it.   The 'somebody elses' of the world would likely be more willing to pay for the care, if there was a way to make the care less expensive. 

senatortombstone
senatortombstone

You cannot get something for nothing. Insurance companies probably do not cover these mental maladies because they are difficult to define, diagnose, and successfully treat. Forcing insurance companies to do so at the point of a government gun is evil and will probably result in less coverage for the mentally ill and higher insurance costs for us all.

DonkeyHotay
DonkeyHotay topcommenter

Mental Illness = America's BIGGEST Health Care problem

hansengigi
hansengigi

the lines between illness and health are very blurry, and political.  my own doctor has told me to lose 60 pounds.  I cannot find success-- despite spending thousands of my own money on various plans and groups.  I would like to try total immersion (similar to the article's subject, a residential treatement plan).  However just like the other ways I've tried, insurance won't cover a dime of it. 

My point is this:  I am basically sort of healthy, but my asthma, depression, and blood pressure are getting worse, and I would be more productive and happier if I could lose weight.  But, Big Insurance doesn't see this as a problem, and won't pay to try to get me "healthier". 

It's not the middle-health people like me who get care, it's the extremely low-health people who get care, just like government benefits--  the middle class pay pay pay their taxes, but the low-income receive the majority of benefits.

AutismMN
AutismMN

Great article.  I hope people will start paying more attention to the laws that protect our most vulnerable people.  

hansengigi
hansengigi

@DonkeyHotay 

you replied to me "stop putting so much food in your mouth. Hope that helps."

Unfortunately, it doesn't help.  I have been faithfully on various low-calorie, low-carb, low-fat, etc diets, and none of them had any long-term success. 

What I need to be healthy will take more than "stop putting so much food in your mouth". 

Everything I've done with my own efforts has failed---that's why I need professional help. 

If a stomach-staple surgery would help lose the weight, reduce my asthma, blood pressure and depression/anxiety, then shouldn't I qualify for that?  But I don't weigh ENOUGH yet, so I don't qualify. 

It is really crazy how they restrict medical care only to the very sickest, or the very youngest, or the very poorest.  Those of us with jobs, sort of sick but not deathly sick, who are paying into Medicare & Medicaid, need medical care too, so we can keep paying for all the 47 percent who pay nothing.

 
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