Reflections on the Year's End

Once again, as we approach the year’s end, it is time to reflect on all that has happened in the world, what we have done, and where we are going. The year 2024 was a big year for our organization.  In addition to the many appeals that we write for families, we now work with two facilities, calling in pre and ongoing authorizations, obtaining single case agreements when networks are inadequate (which they frequently are), submitting claims, pursuing payments and ensuring that facilities and families are appropriately paid and/or reimbursed for services received. 

We have stepped up our motto of not taking no for an answer, and continually push back on health plans when they attempt to deny core mental health and autism treatments due to plan exclusions.  After carefully reviewing the Federal government’s updated Requirements Related to the Federal Mental Health Parity and Addiction Equity Act (MHPAEA), released in September of this year, we have been diligently working to inform and partner with both representatives at the US Department of Labor (EBSA), as well as Health and Human Services (CCIIO) who are charged with regulating self-funded health plans.  We have found that for the first time in many years, mental health and autism issues are now front and center priorities for these agencies, in terms of trying to serve consumers needs and obtain much needed treatments, especially when they are denied due to issues of access, inadequate networks, and some hardline exclusions. It continues to be an imperfect system, however. Neither office maintains medical staff that are equipped to evaluate appropriateness of treatment. At times, we have been told that they simply do not have the person power to follow through on big ticket items. If your plan is not processing your appeal, or repeatedly making errors, they often intervene and get the plans to respond. See below on "Parity in Practice" for more details.

With changes on the immediate horizon on the federal level, however, we are left with many unknowns on whether Mental Health Parity will be a priority for the new Trump administration, as it was within the Biden administration.  Though Mental Health Parity is a bi-partisan issue and clearly impacts people on both side of the political aisle, and we are cautiously optimistic about Trump’s choice for Secretary of Labor, Lori Chavez-DeRemer, who is thought to be pro-labor, we are concerned that job cutbacks at all federal departments will contribute to workforce shortages and setbacks.  And while progress on MHPAEA enforcement was clearly made during the Biden years, there are simply too many unknowns to speculate on what lies ahead. 

Regardless, MHAIP will be there advocating on both the state and federal level, helping families, providers and facilities get the services that they need through their health care plans.  Your end-of-year contribution will help offset our sliding scale, making services available to those that would otherwise be hard pressed to afford it (Donate to the Feda Fund). It also helps to pay for staff training, advocating and implementing favorable policies on the state and federal levels, educating legislators and regulators, and training families about their rights, so that they can do some of this work themselves.(Donate to the General Fund). Please help us with our mission by continuing to give.  Your gift helps make the difference. 

Happy Holidays and enjoy the holiday season.

Sincerely,

Parity in Practice

As we look forward to the new MHPAEA (Mental Health Parity and Addiction Equity Act) rules beginning in January 2025, it’s heartening to see the Department of Labor open new investigations into both quantitative treatment limitations, and non-quantitative treatment limitations. MHAIP cases include complaints for individuals denied the right of ongoing care while undergoing an appeal process, and a health plan using unqualified reviewers to handle autism cases. 

We continue to use the Department of Labor’s template complaint forms to identify these issues and request comparative analyses. Health plans are still applying discriminatory standards for mental health residential treatment centers, specifically applying broader standards of nursing/MD availability, which do not reflect the Generally Accepted Standards of Care (“GASC”) for mental health.  To summarize:

• The plans must conform to generally accepted standards of care (GASC) in how they provide and treat mental health/SUD in a residential setting and how they provide and treat medical/surgical conditions in skilled nursing and physical rehab settings.
• GASC for mental health/SUD does not require 24/7 nursing care or weekly psychiatric visits. These are not accepted or established practices. They are generally not required in the guidelines developed by non-profit professional societies, nor are they indicated in the accrediting bodies that accredit these facilities, nor are they mentioned in state licensing requirements. Many states have well documented psychiatric shortages and simply do not have enough psychiatrists to provide weekly treatment nor RTC facilities with 24/7 onsite nursing.  
• GASC on the medical/surgical side for skilled nursing and physical rehab centers do require 24/7 nursing care, both within state licensing requirements, and by Medicare, and likely in accreditation standards.
• Requiring more stringent requirements, in this case, that Mental health residential centers go BEYOND generally accepted standards of care and state licensing requirements, is an overly restrictive treatment limitation which results in network inadequacy on the mental health side of the plan and actively blocks access to a core treatment for a mental health condition. It actively discriminates against people with serious mental health disorders and creates a shortage of appropriate centers along the mental health continuum of care. 

However, despite promising engagement from the Department of Labor on MHPAEA treatment limitations, the Department is inconsistently able to enforce compliance with provisions from both the Affordable Care Act and ERISA, including requiring detailed reasons for denial in writing, and requiring timely and appropriate responses to appeals and external reviews. This is frequently offset, however, by a willing and cooperative employer.

Sara Du Terroil

Appeals Specialist

Making Sense of the UHC CEO Assassination

Recently, United Health Care CEO Brian Thompson was assassinated in NYC in the early morning hours of December 4. Bullet casings found near the scene were etched with the words "deny," "delay," and "depose." This tragedy unleashed a barrage of online hate against health insurance companies, the decisions they make, and way they manage their members. While MHAIP in no way condones this act of violence and offers our sympathy to those that loved and worked with Mr Thompson, this horrific event presents an opportunity for those in the health insurance industry to take note that a large number of beneficiaries are VERY unhappy with the way that health care is managed in this country and that profound changes are drastically needed. If you work for a health insurance plan, please listen to your members. Know that the decisions that you make hold profound power over their lives, including life and death, and whether they live in poverty, debt and chaos. Read their complaints and appeals, and respond to them timely, appropriately, and with kindness. Look at what is right, and not just the cost. Don’t be afraid to stand up to power and do the right thing. When you pick up the phone, ask "how can I help?" This is not a game, these are people's lives. We are all in this world together, actions have consequences, and we can all make a difference. 

Highlights From Recent Appeal Wins

3 1/2 Months of RTC

We won 3 ½ months of RTC level of care for a 16-year-old trans boy struggling with severe depression, post-traumatic stress, self-harm and suicidal ideation. Evernorth Health Services (Cigna) denied his stay at an RTC after three weeks, but due to the detailed medical records and his history of past IOP, PHP and RTC care that did not improve his symptoms and behaviors, Evernorth overturned its denial at the first level of appeal, which is rare. We are continuing to appeal for more dates to be covered by Evernorth.

"Three weeks into, what so far has been a nine month stay at a long term Residential Treatment Center, our insurance company denied our son’s coverage. Since then, they have made things as difficult as possible by withholding information, providing contradicting and sometimes incorrect instructions, and delays in communications (just to name a few examples). Luckily, we had the MHAIP team in our corner. Debra did an amazing job in preparing detailed and effective appeal documents. She worked closely with our son’s treatment team (who mentioned to us how knowledgeable she was) to help them draft a letter of medical necessity. With MHAIP’s advocacy, we were able to get an additional 15 weeks of coverage approved (the time period for which we had filed an appeal) and we are currently in the process of requesting coverage for additional dates. We are sincerely grateful to the team at MHAIP." Melanie M, NJ.

Entire 8 1/2 Weeks of RTC Covered

Update: MHAIP won, on an overturn, the approval of admission, and subsequently, the entire 8 week stay at an at residential treatment center in Southern CA for a 15-year-old girl struggling with autism, depression, anxiety, selective mutism, and disordered eating. This was a complex case because the girl had already spent 7 weeks at an eating disorder-focused residential treatment program and Anthem did not want to approve admission to another behavioral health RTC. We were able to show the severity of her symptoms and that all other types of outpatient and partial hospitalization programs had failed, which resulted in an overturn of the denial.

"We recently navigated a challenging situation when our ASD teen was denied pre-authorization for a medically necessary residential treatment program after a peer-to-peer review. Thankfully, Karen Fessel connected us with Debra Nelson, whose expertise and swift action made all the difference. Within just 30 minutes of a 2.5-hour review process, Anthem reversed their decision, granting 7 days of coverage for an in-network residential treatment program specializing in ASD and related co-morbidities.

Moreover, thanks to Karen and Debra's continued guidance, we ultimately secured 8.5 weeks of coverage, allowing our child to achieve critical medical stabilization. Their thorough understanding of the system and her ability to advocate effectively provided immense relief. They also advised us on potential strategies for pursuing coverage for the long-term care our child will need. 

What stood out most was MHAIP's integrity and professionalism. They knew exactly when to transition our case to other experts, ensuring we received the best support while being mindful of our resources. Their thoughtful approach saved us both time and unnecessary expenses. We’re deeply grateful for the advocacy and would highly recommend them to any family facing similar challenges." Anjali P. NJ

Followed Through for Reimbursement of $77,500 from Aetna

Update to a previous win approving 7 weeks at inpatient psychiatric level of care: We assisted our client in untangling a stalemate between Huntsman Mental Health Institute and Aetna that was resulting in incomplete reimbursement for a 7-week inpatient psychiatric stay for her son. We kept an eye on the various forms and documents that both Aetna and Huntsman required to process the reimbursement and got the California Department of Insurance involved when Aetna and Huntsman did incorrect and highly dubious things. We are happy to report that Aetna eventually reimbursed our client the complete $77,500.

Entire 3 Month Stay at RTC for 16 Year-Old Male

We won coverage for a 3 month stay at a residential treatment center for a 16-year-old from WA with unsafe and provocative behaviors who had suffered sexual abuse as a young child. Despite clear evidence of the boy’s unsafe and destructive behaviors while at the RTC, Regence denied coverage at admission and refused to cover any dates. Our clear and convincing documentation of the efforts the family tried over the years to help him with his aggressive and destructive behaviors resulted in a completed overturn in external review, thereby approving his entire stay.

74 Days of RTC Coverage Won on Level 2 Appeal

MHAIP worked with the family of a 16-year-old female with Major Depressive Disorder, ADHD, and Cannabis and Alcohol Use Disorder to appeal the denial of a set of dates for treatment at a residential treatment center in Utah.  Dates prior to, and following, the denied set of dates were authorized and covered, but due to an administrative error by the billing company, there was a significant gap in authorized dates.  MHAIP filed and lost the Level 1 Appeal.  Our Level 2 Appeal highlighted the many ways our client met medical necessity, noted the insurer’s procedural failures, and included a strong letter of medical necessity from the treating therapist.  We ultimately won coverage for the 74 days of residential care.

Additional $80k Won for Network Exception

MHAIP appealed denial of a Network Exception (where a health plan lacks an inadequate network and is required to cover all but in-network cost-shares) for a young adult from upstate NY with Generalized Anxiety Disorder, Major Depressive Disorder and ADHD. The insurer, Excellus, did not have any appropriate in-network options for the member who received care at an out-of-network RTC in New Hampshire. The family properly explored the network with Excellus before their son admitted for treatment and argued that Excellus could not provide any options. Yet, Excellus continued to deny a Network Exception. After losing on appeal, MHAIP took the case to the New York Attorney General's office and filed a complaint. The NYAG eventually compelled Excellus to cover his treatment with a Network Exception. After well over a year of our work, the family received an additional $80k, which included $9k in interest due to NY prompt pay laws.

"My family and I am truly grateful to Marcy, Karen and the team at MHAIP. Without their support and hard-work we would not have received an out of network exception and a settlement of almost $80,000 that resulted in the majority of our child's care being covered. I appreciate their persistence in making the insurance company pay as well as all the patience and kindness directed to this overwhelmed parent. It would not have been possible without them." Amy S, NY. .

Highlights of Pre-Authorization/UR Services

WS, a 20-year-old from MD with ASD level 1, received 238 days of coverage from Care First BCBS at a residential treatment center in Utah.  

BG, a 20-year-old from MA with Anxiety Disorder and Depression received her entire 122 day stay covered by BCBS at a residential treatment center in New Hampshire.

JA, a 13-year-old from Maine with Other Specified Anxiety Disorder, Gender Identity Disorder and Autism Spectrum Disorder received 89 days of coverage from Anthem at a treatment center in New Hampshire.

DI, a 16-year-old from Hawaii with Generalized Anxiety Disorder Major Depressive Disorder and ADHD received 81 days of coverage (to date) from HMSA at a treatment center in New Hampshire.

GN, a 14-year-old from NJ, with Generalized Anxiety Disorder, Social Anxiety Disorder, Major Depressive Disorder and ADHD had 55 days to date of her stay covered by UMR at a residential treatment facility in New Hampshire

JL, a 16-year-old from NY with OCD and GAD received 49 days of coverage (to date) by Fidelis at a treatment facility in New Hampshire.  

GL, a 16-year-old from CA with ADHD, Oppositional Defiant Disorder and other Compulsive D/O received 35 days of coverage (to date) by BSOC at a treatment facility in Hawaii.

LS, a 15-year-old from CA with ADHD and other specified depressive disorder received 24 days of coverage (to date) by Anthem at a treatment facility in Hawaii

TM, a 14-year-old from CT with OCD & ADHD received 36 days retroactive at a treatment facility in New Hampshire.

MP, a 16-year-old from NY with Major Depressive Disorder and Generalized Anxiety Disorder received 29 days (to date) coverage by AETNA at a treatment facility in Hawaii.

MHAIP on the Road

MHAIP Executive Director Karen Fessel

and Appeals Specialist Sara Du Terroil

at the Autism Law Summit in October, Boise, ID

Donate Now to our General Fund

General Fund supplements our sliding scale program, pays for educational seminars and workshops for families and professionals, helps with policy work and allows us to provide free advice to families needing help with insurance.

Donate to the Feda Fund

We will need your continued financial support to be able to keep this wonderful program, which allows us to provide assistance to financially struggling families and keeps Feda and Mu’s memories alive in our hearts.  Thank you for your active support.