Denying Our Insurance Rights

Statehouse

My son Alex died of a heroin overdose on May 11, 2015. Some might attribute Alex’s death, and the deaths of others like him, to personal choices. But this view is simplistic. It obscures more than it illuminates. The search for reason and solutions can’t simply rely on blaming those who overdose.  

One critical place we can look is at insurance policies, and the need to guarantee parity. October 2018 marked the tenth anniversary of the federal parity law that requires insurance companies to provide equal coverage for mental health and substance use disorder treatment. According to the Mental Health Parity and Addiction Equity Act (MHPAEA) law, insurance companies are prohibited from imposing higher financial requirements, in-network requirements and similar treatment limitations on people seeking mental health or substance use disorder (SUD) treatment compared to other health care services.   

The passage of this law was an important success, but its potential hasn’t been realized at the state level. In the 10 years since its enactment, enforcement of the law has been lacking, leaving thousands of New Jersey residents at risk for insufficient treatment options and prohibitive expenses. Insurance policies typically don’t reimburse for more than 30 days of residential treatment, and that’s for people fortunate enough to have coverage for mental health and SUD treatment. SUD patients need long-term, supportive, evidence-based treatment facilities, and follow-up community recovery efforts. They need help paying for these services, as they would if they were patients being treated for cancer or high blood pressure. Insurance companies are not supporting that level of care. People are dying because of that neglect. Families are devastated because of that neglect. Most of the care and financial burden for SUDs ultimately falls on families, and the vast need for services and insurance support remains unmet.  

Alex was just days away from entering a year-long program when he died. Few, if any, of the charges for the program he was about to enter would have been covered by our insurance provider, Horizon Blue Cross/Blue Shield. We would have paid the thousands of dollars needed over that next year to help make him better. But it was too late. 

Horizon Blue Cross/Blue Shield has also repeatedly denied us reimbursement for mental health/SUD services we pre-paid for Alex at a psychiatric hospital in 2014. The appeals process is a bureaucratic nightmare, not for the faint of heart. We have gone through multiple appeals, both through our insurance company and the state’s regulatory appeals process. The crux of the argument involves who should pay for supervised living services—room and board for inpatient residential treatment facilities. Though these services are required as part of the treatment process, they are not viewed as an eligible benefit under our policy and are authorized only as intensive outpatient treatment. I’m not a lawyer, but there is no question in my mind that had Alex’s illness been diabetes or cancer, we would have been reimbursed years ago. 

Perhaps four years isn’t a lot of time for an insurance company to drag out an appeals process, but the nine months between August 2014 and May 2015 when Alex was still alive, we were holding our breath, hoping he would survive. Since that day in May when our lives were forever shattered, I’ve continued the appeals process— for us, but also for other families struggling with SUDs. My family, and countless other families, have gone through more than a lifetime’s share of defeat and heartbreak because this insurance system is broken.  

Insurance discrimination is illegal. The national parity law is on the books, it needs to be enforced. As the Kennedy Forum has argued, the leadership on parity is not happening at the federal level. The recently passed opioids legislation contains no parity provisions. It’s time for New Jersey public officials to take a more active approach. A new bill (A.2031/S.1339) being debated in the New Jersey legislature would require insurance companies to file annual reports that demonstrate compliance with the federal parity law. Health advocates in several states, including New Jersey, have formed the Parity at 10 Campaign and are rallying for these types of changes. Their demand is both simple and straightforward: regulators should require insurance companies to demonstrate that they comply with federal parity requirements before they are allowed to sell their plans, monitor compliance through data auditing, and provide direct assistance to help consumers secure their right to equal coverage.  

The federal parity law was designed to help solve the opioid epidemic, but it cannot achieve its promise without vigorous enforcement and accountability at the state level. New Jersey must fully protect the rights of its citizens to receive the health care they need and to which they are already legally entitled. Lives have already been lost, and more lives are at stake. We can and must do more.   

Alex had everything to live for. He had a plan in place and was headed back to school. He had a sober living environment to move to, and people (including a loving family) who were supportive. It wasn’t enough.  

Make sure your legislators hear that you support moving parity legislation forward. Many more lives hang in the balance. 

Patricia A. Roos is a Professor of Sociology at Rutgers University-New Brunswick.

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