Insurers Often Don't Cover Residential Rehab | Connecticut Public Radio

Insurers Often Don't Cover Residential Rehab

Mar 21, 2014

Connecticut's Office of the Healthcare Advocate exists to help consumers. Demian Fontanella is General Counsel for OHA and worked on the Harmons' appeal.
Credit Lucy Nalpathanchil

In 2012, a legislative committee found seven percent of Connecticut adolescents between the ages of 12 and 17 had substance abuse issues. And the majority of those who needed treatment did not receive it.

In the last story of a three-part series, WNPR reports on the challenges families encounter with their insurance plans when seeking help for their teenage son or daughter.

Earlier this week, we introduced you to the Harmons of Guilford whose teenage son almost died from an overdose in 2011. Since then, Tim has been in recovery, but there have been detours.

One of the first bumps came after Tim went back to his high school and encountered the same pressures to use drugs. His father, Justin Harmon, said Tim spent a total of a year and a half in residential treatment programs, including two stints at Rushford at Stonegate, an adolescent program in Durham.

The Harmons had considered sending Tim to a program in Arizona until they found Turning Point in New Haven, a residential treatment program for young men. Tim went there when he was 18. "When he was leaving Rushford, and it was clear he needed more care," Justin Harmon said, "it was a real challenge to find Turning Point. People in the health care community didn’t know [about Turning Point]. I was astonished. I mean, if this is such a  big problem, why isn’t there information on where to turn?" 

There are few residential rehabs for adolescents. The ones in Connecticut vary in what gender and types of payments are accepted.

The care Tim Harmon received was expensive, and it took a toll on the Harmons’ finances when their insurer at the time, Anthem, refused to pay for any of their son’s residential treatment. "That’s criminal," Justin Harmon said. "We’re fortunate, because we have the resources to make up the difference. Tim would be dead if we hadn’t. I believe that with all of my heart."

The Harmons cashed out retirement accounts to pay the bills while they appealed Anthem’s decision. They had help from Connecticut's Office of the Healthcare Advocate. OHA General Counsel, Demian Fontanella, said a majority of the offices cases are appeals for denials of mental health and substance abuse treatment. 

Fontanella said that insurers follow criteria for what its reviewers deem  “medically necessary.” The problem is the  insurer’s idea of what’s necessary often is not what the health care provider has recommended. "The insurers won’t necessarily deny care altogether," said Fontanella. "They’ll deny after a week, or two weeks, or a month. Even though a clinician may recommend a minimum of three months, the carrier says, 'No, you no longer need this level of care, based on the criteria.'"

Arms Acres in Carmel, New York sees this often with commercial insurance. "They may give us five days to start," according to Earl Wiggins, Director of Adolescent Programs at Arms Acres. The residential rehab, near the New York-Connecticut state border, treated more than 100 Connecticut adolescents last year.

Wiggins said, “With Medicaid, they give us time to work with them  a little big longer. But with commercial insurance, we have to justify keeping them another five days and more often than not we have to deal with the ten or 15 days they [commercial insurance] might give us. And then we do what we call the microwave version.” Wiggins said managed care really limits residential rehabs from offering a traditional 28-day treatment program.

Rushford in the Hartford HealthCare behavioral health network sees families with the same  insurance plans. Rushford said sometimes families have to pull their kids out of care because the insurer won’t cover the recommended treatment days.

These decisions have enormous consequences, according to Dr. J. Craig Allen, Rushford Medical Director and a Child and Adolescent Psychiatrist. He said, “If there has been no chance to work with the family, if there’s been no chance to establish outpatient resources and a sober environment, a sober support group. Chances are 100 percent this kid is going back to the same high school, have the same people hanging around him, have the same numbers on his phone, and is going to be using again.”

There is a provision in a new state law aimed at improving the way insurance companies make decisions. It requires insurers to use clinical peers with experience in the delivery  of mental health and substance abuse services to review appropriate cases. The law just went into effect in October, so advocates are hopeful its impact can be measured in the near future. This was one of the recommendations of the Office of the Healthcare Advocate.

Eventually, OHA was successful in getting Anthem to pay for more of  Tim Harmon’s residential care. His father said they still had out-of-pocket expenses over $60,000, but the reversal helped blunt the cost to them. More importantly, their son just turned 20, and is doing better, working part-time, and has plans to enroll in a college within commuting distance. 

The Harmons shared their story because they know many families are dealing with addiction. Tim's mother, Mary, said families shouldn't feel ashamed. "It's a scary thing," she said. "He's so young. You watch for his quietness. I always look in his eyes. I want to see white in his eyes. I don't want to see bloodshot. You know, we came real close to losing Tim, and we got lucky."

Mary Harmon said they take it one day at a time.