Seabrook House terminated its contract with Aetna effective July 7, after receiving dozens of denials for residential addiction treatment deemed medically necessary by Seabrook House physicians.
The New Jersey-based treatment center, which has been a frequent critic of health insurers with regard to addiction treatment limitations, contends that Aetna's conduct is inconsistent with the federal Mental Health Parity and Addiction Equity Act of 2008 and The Affordable Care Act of 2010. The 2008 parity law requires group health insurance plans that offer coverage for mental illness and substance use disorders to provide those benefits in no more restrictive way than all other medical and surgical procedures covered by the plan.
"We have been on the front lines in the war on drugs and we have found that often the hardest battle we fight each day is with the insurance companies that are in the business of denying the coverage its members are entitled to receive," said Ed Diehl, President of Seabrook House.
Diehl expressed particular frustration over what Seabrook House maintains as a deliberate strategy by Aetna and other insurers to “knock down” access and availability to treatment for the rising numbers of young people who, thanks to the ACA, are now able to remain on their parents’ health insurance contracts through age 26.
"Young opiate addicts are dying of drug overdoses every day, and those that are seeking treatment for their addiction are being denied the proper level of care." Since the Affordable Care Act’s insurance provisions went into effect, Diehl says that the number of denials for those 18 to 26 years old has “skyrocketed."
Another bone of contention involves insurers’ use of non-published medical necessity criteria to make care authorization decisions. Diehl contends that “New Jersey state licensing requirements for treatment facilities require that we follow American Society of Addiction Medicine patient placement criteria (ASAM-PPC-2). When an insurer refuses to allow admission because they ignore those criteria, we can’t follow our licensing requirements. We’re on our own.”
Then, the question becomes, ‘do we or don’t we want to do business with this insurer?’ In this case we decided that it’s just not worth it,” said Diehl. "Aetna needs to realize that the cost of denying treatment now will ultimately cost so much more in the future. Those left untreated or not approved for the proper amount of treatment face deeper physical and mental health obstacles as the disease of addiction progresses."
The fact that the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 is not yet backed by a final implementation rule—an aging interim final rule remains in place—“doesn’t negate the requirement of insurance companies to follow the law,” said Diehl.
While he hopes that a final parity rule may provide more detailed clarification, he contends that “there are serious violations of the rights of Americans seeking addiction treatment. The government,” he adds, “has failed to protect the interests of citizens and, in the face of entities that don’t believe there’s a problem, we want to make it clear that there is a big problem.”
To back its claims, Seabrook House has made available de-identified records of more than 60 claims denials by Aetna and other insurers. These denials are being collected by the National Association of Addiction Treatment Providers from its member entities to support a push for stronger federal parity enforcement.