Insurance coverage sought for mental, substance-abuse care

New Jersey residents are being wrongly denied insurance for inpatient treatment for substance abuse and mental illnesses, forcing them to choose between paying for expensive care or being put on the streets, a group of patients, family members, and health-care providers told a legislative committee Thursday.

The group told the Senate Legislative Oversight Committee that the state should take a more active role in advocating for patients, saying that those with behavioral or substance-abuse issues aren't treated the same as those with physical ailments.

For instance, the state's Medicaid program provides inadequate reimbursement rates for treatment, said Debra L. Wentz, chief executive officer of the New Jersey Association of Mental Health and Addiction Agencies.

"Usually you get what you pay for, but in the case of providing the treatment and services for mental illnesses and substance-use disorders, the return on investment is huge," Wentz said. "And if there is not adequate investment, then the cost to taxpayers in the consequences of untreated mental illness and addictions can break the bank."

Mental-health and addiction services are covered by a variety of payers, including Medicaid, private insurance, and public employee benefit programs, plus charity care. While the committee examined the issue in its role to provide legislative oversight to the executive branch of government - which operates the Medicaid and public employee benefit programs - it considered issues related to all of the payers.

Sen. Robert M. Gordon (D., Bergen), the committee chairman, said he would consider introducing a bill based on a Pennsylvania law that requires insurers to cover treatment recommended by doctors for a 30-day period.

Currently, a patient with private managed care insurance undergoes a review by a utilization management company hired by the insurer. That company can determine that the treatment recommended by the patient's health-care providers - including the length of stay for inpatient treatment - isn't medically necessary. The patient can then appeal that determination and ask for an independent review, but the families said the process has broken down and is leading to too many negative results for patients.

"There are a great number of people who are not getting the kind of care they need," Gordon said. "It affects families and it affects society."

The debate focused on how insurance companies define what is "medically necessary," with attendees saying that the companies unfairly refuse additional days of inpatient care or therapist sessions.

However, insurance industry advocates said the system provides appropriate checks and balances that allow patients to appeal decisions and that the measure mentioned by Gordon would reduce the ability to avoid unnecessary treatment.

"The system that's in place allows an appeal and allows someone outside the health plan to hear the appeal," said Wardell Sanders, president of the New Jersey Association of Health Plans. "To allow automatic coverage for 30 days would certainly blunt the effectiveness of tools to weed out inappropriate utilization and control costs."

The testimony depicted a series of situations in which patients were denied care after their providers recommended it.

Nancy Walsh described the plight of her son, James. She said he has had a series of denials in seeking treatment for addiction.

James said he lost nearly six years of his life to heroin addiction after being denied inpatient treatment recommended by providers. He has been in recovery for a year after finally receiving that treatment.

Much of the testimony was coordinated by HealthCare Assistance with Member Support L.L.C. (HCAMS), a company that provides behavioral health assistance to employees, including public worker union members.