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Times-Union: NY Assembly Hears Conflicting Views on Addiction Coverage

By Claire Hughes, Albany Times-Union, 6/9/14

A discussion convened by several Assembly committees about insurance coverage for addiction treatment heated up Monday when a participant pulled out her son’s ashes.

“This is what happens in the interim of fighting for the benefit I pay for monthly,” Linda Ventura of Long Island said, referencing her inability to convince her insurance carrier to cover treatment for her son before he died of a heroin overdose two years ago at age 21.

She held up a Rubbermaid container filled with ashes for the couple of dozen participants assembled around a long table to see and demanded that Paul Macielak, president of the New York State Health Plan Association, an insurance industry group, look her in the eye as she spoke. Ventura bristled when Macielak raised a thorny question about whether insurance companies or the state will be required to pay for all physician-prescribed treatments, as is being considered under a legislative proposal.

“It goes to, Who’s going to pay for it ultimately?” Macielak said.

“I paid for it ultimately, sir,” Ventura replied.

Their clash stood out in the otherwise polite discussion, a roundtable format in which participants spoke and responded to each other in an orderly but relatively free fashion, compared to a hearing in which they are questioned formally. Assembly committees on health, insurance and alcoholism and drug abuse convened the meeting as legislators consider several proposals to address what state and local experts refer to as an epidemic of heroin and opioid abuse.

On Monday evening the state Senate passed its own package of bills intended to address the surge in heroin and opioid use.

Ventura was one of several parents in a room at the Legislative Office Building Monday who lost children to overdoses after denials of insurance coverage. Also at the table were treatment providers, who expressed frustration over discrepancies between the state rules they must follow and what they characterized as obscure insurance company criteria for coverage. Parents and providers both bemoaned a lack of treatment options in the state — for intensive outpatient, detox and recovery services, among them — that required to deliver appropriate levels of care to addicts at various stages of getting clean.

Meanwhile, insurance industry representatives and state officials from agencies governing insurance and treatment providers described a shifting landscape of federal law and state rules likely to challenge lawmakers attempting to draft legislation that would effectively address the current crisis.

Assembly Health Committee Chairman Richard Gottfried and Insurance Committee Chairman Kevin Cahill expressed disappointment that the state Health Department did not participate in the discussion.

Among the contentious issues most frequently criticized by parents and providers was a “fail first” requirement of some insurance companies — the idea that an addict must prove unsuccessful at staying clean while receiving less intensive, outpatient services before being approved for more intensive, residential treatment. Parents and providers also complained about the inconsistency of insurance company determinations on “medical necessity,” the basis of many coverage decisions.

A push to place patients in “least restrictive” environments is happening throughout health care, Macielak countered, as reforms seek to produce a healthier population at less cost. Close to 80 percent of the 609 appeals filed since 2007 to fight coverage denials for inpatient substance abuse services have upheld the insurer’s decision, according to Troy Oeschner, deputy superintendent for the state Department of Financial Services, which oversees health plans.

But patients dependent on opiates are treated differently from others — they are routinely denied care, even as those on other drugs are more likely to get treated, said David Bochner, vice president of the Addiction Treatment Providers Association. The insurance company response is, “You can’t die from withdrawal, go to outpatient first,” he said.

Keith Stack, executive director of the Addictions Care Center of Albany, said it’s the drive to relieve themselves of the pain of withdrawal that puts heroin users in urgent need of care.

“The one solution to fight the withdrawal is to use more heroin, and that’s what happens,” Stack said. “That’s where the risk of death comes in.”

Sean Doolan, an attorney representing the state’s Blue Cross and Blue Shield insurance plans, called recent public debate about insurance coverage for addiction treatment “eye-opening.” Insurers are working to limit “fail first” as a response to coverage, he said.

“As this crisis has emerged and it’s become an epidemic, the marketplace and the industry is evolving,” Doolan said.