After Schneiderman’s office investigated the situation, the health insurer has agreed to change its procedures for evaluating treatment claims for the behavioral-health conditions.
The attorney general announced the investigation and settlement in a news release his office distributed on Wednesday.
Rochester–based Excellus, which is part of the Blue Cross Blue Shield Association, has 1.5 million members and is upstate New York’s largest health plan, according to the news release.
The settlement also requires Excellus to notify 3,300 members that they can make a second claim for inpatient, substance-use disorder rehabilitation and eating-disorder residential treatment. Excellus had denied their initial claims between 2011 and 2014, Schneiderman’s office said.
The estimated value of Excellus’s denial of these individuals’ requests is up to $9 million, Schneiderman’s office said.
The office’s health-care bureau conducted an investigation that found Excellus denied inpatient substance-use disorder rehabilitation-recovery services seven times as often as inpatient medical services.
“My office has taken an aggressive approach to enforcing mental health parity laws that I hope can serve as a national model,” Scheiderman said in the news release.
“Mental health and addiction recovery treatments must be regarded the same as other health insurance claims under the law. We will continue to take on those who ignore the law and reinforce the false and painful stigma often associated with these ailments.”
The settlement with Excellus is the fifth since last year for Schneiderman’s office in enforcing the mental-health parity laws.
Insurers that include Schenectady–based MVP Health Care; Bloomfield, Connecticut–based Cigna Health and Life Insurance Company; and New York City–based EmblemHealth have already entered into settlements. Schneiderman last week also reached a settlement with Norfolk, Virginia–based ValueOptions, the behavioral-health vendor for both MVP and Emblem.
“We commend Attorney General Schneiderman and his staff for fighting to ensure mental health parity,” Glenn Liebman, CEO of the Mental Health Association of New York State, said in the news release. “The tenets of mental-health parity are to ensure access to services, expand networks of care, eliminate barriers that don’t currently exist for physical-health benefits and create a strong right to appeal. These settlement agreements address many of these concerns. These agreements also send a strong message to the community that people are entitled to quality behavioral health care.”
New York in 2006 enacted its mental-health parity law, known as Timothy’s Law. It requires insurers to provide mental-health coverage “at least equal” to coverage provided for other health conditions.
The federal Mental Health Parity and Addiction Equity Act, enacted in 2008, prohibits health plans from imposing greater financial requirements or treatment limitations on mental health or substance-use disorder benefits than on medical or surgical benefits.
Schneiderman’s office noted that Excellus, based in Rochester, is part of a community that’s had an “opioid overdose epidemic with deadly consequences.”
Heroin overdoses in Monroe County have doubled in recent years, and have increased “fivefold” since 2011.
Monroe County had 65 heroin-related deaths in 2013, the office said.
Access to substance-use disorder treatment, including inpatient-rehabilitation treatment, is “vital to addressing this scourge.”
The investigation revealed that many of Excellus’s inpatient substance-use disorder rehabilitation denials were the result of its requirement that members “fail” outpatient treatment “multiple” times before accessing such care.
That conflicts with New York’s guidelines and Excellus doesn’t apply it to medical care, Schneiderman’s office said.
The investigation also indicated that some of the denials appear “arbitrary and wrongly decided,” and that Excellus did not cover residential treatment for behavioral-health conditions in its standard contract.
In one case, Excellus denied residential-treatment coverage, “due to lack of a benefit,” for a 16-year old girl suffering from the eating disorder anorexia nervosa, according to Schneiderman’s office.
The girl was also at 83 percent of ideal body weight; had amenorrhea (the absence of menstruation); malnutrition; unstable vital signs; and bradycardia (a dangerously slow heart rate). The girl later attempted suicide and had to be hospitalized in a medical unit, the office added.
Under this agreement, Excellus will provide notice of a new appeal right to 3,300 members whose requests for inpatient substance-use disorder rehabilitation and residential treatment were denied between 2011 through 2014.
These members will get a chance to file an independent appeal, if they paid out of pocket for the treatment that Excellus denied, and did not previously file an external appeal.
Contact Reinhardt at ereinhardt@cnybj.com