Treating Addiction with Fail-Safe vs. Fail-First System

Addiction Treatment In The News…

If you have a few minutes, open an internet browser and try completing a search or “Googling” the phrase “addiction treatment.”  On any given day the general search engine results will be somewhere in the neighborhood of 157,000,000 and news results could be around 450,000. Imagine now being the parent, spouse, sibling, child or close friend trying to find treatment for your loved one.  Complicating the search is determining if the person in need of treatment is covered by a health insurance policy which has behavioral health coverage including addiction treatment.

Parity, The Affordable Care Act, And ‘Addiction Treatment’ Coverage

It was in November 2013, the Department of Health and Human Services (HHS) issued its final rule to increase parity between mental health/substance use disorder benefits and medical/surgical benefits for individual and group health plans.  These rules were to implement the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). While the MHPAEA was originally written to apply only to group health insurance coverage, the Patient Protection and Affordable Care Act of 2010 amended the MHPAEA to include individual health insurance policies.

Within the 2013 HHS final rules the following consumer protections were also included:

  • Ensuring that parity applies to intermediate levels of care received in residential treatment or intensive outpatient settings;
  • Clarifying the scope of the transparency required by health plans, including the disclosure rights of plan participants, to ensure compliance with the law;
  • Clarifying that parity applies to all plan standards, including geographic limits, facility-type limits and network adequacy;
  • Eliminating the provision that allowed insurance companies to make an exception to parity requirements for certain benefits based on “clinically appropriate standards of care,” which clinical experts advised was not necessary and which is confusing and open to potential abuse.

Some States Look To Regulate How Health Insurance Companies Assess Level Of Addiction Treatment

New York…

In New York, Assemblyman Michael Cusick sponsored a bill which was signed into law in June 2014 and will take effect on April 1, 2015.   According to an article published by,  Cusick’s legislation would:

‘…require health insurance coverage for substance use disorder treatment services and create a workgroup to study and make recommendations for its implementation.

Cusick said the legislation will improve access to care by requiring insurers to use peer-reviewed, nationally recognized clinical review criteria when making decisions regarding the medical necessity of treatment.

“In an overwhelming number of cases, insurers are allowing patients with addiction problems to ‘fail first’ at outpatient treatment facilities before they will cover the necessary inpatient stay,” he said. “This bill is an important next step to ensure those seeking treatment can access the services that are appropriate for their situation.”‘

New Jersey

In early February 2015 the New Jersey Senate Commerce Committee heard testimony on bill S2180.  While the bill was first introduced June 16, 2014, it was referred to the Senate Budget and Appropriations Committee on February 9, 2015, and testimony was provided by those working in the addiction treatment field and medical officers from various health insurance companies.

According to a press release republished on the bill was passed out of committee with a vote of 4-2 in favor for the bill to be moved to the next step on the way to becoming law.  The bill was amended by the committee to require and include the following:

  • inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
  • treatment at a State-licensed detoxification facility;
  • participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility;
  • office visits with a health care provider; and
    treatment at home and community-based service facilities.

Treatment or participation at any facility, hospital or office shall

not preclude further or additional treatment at any other eligible facility, hospital or office.

As amended, the bill further provides that, notwithstanding any

law or regulation to the contrary, the benefits provided pursuant to the bill shall not be subject to any utilization management review or medical necessity determination other than the determination of medical necessity by a health care provider.

Perhaps the most striking part of these amendments is: benefits provided shall not be subject to any utilization management review or medical necessity determination other than the determination of medical necessity by a health care provider.

Some Final Thoughts…

Seeking help for addiction treatment and mental health care has been an ongoing struggle for decades. Anyone who has had the experience of trying to obtain treatment for their loved one is, of course, always searching a fail-safe answer, not unlike how we approach dealing with any disease.

At Family Recovery Specialists our mission is to help you realize your hope of a life of recovery from drug abuse and alcohol abuse, for you or your loved one through an individualized, comprehensive, and customized treatment experience. Our services are delivered in a compassionate and caring fashion utilizing clinical excellence while maintaining a person’s dignity. We team together with you through the journey from intervention to after care services in order to restore families and empower the individual in recovery.

Tap to GET HELP NOW: (855) 251-0493