For too long individuals with Mental Health and Substance Use Disorders (SUD) have struggled with pervasive issues of stigma and discrimination that has been fueled by decades of media driven false beliefs and misinformation about the causes and prevalence of these disorders. Examples of false beliefs include ideas like “People should just snap out of their depression and pull themselves up by their boot straps,” “Addiction is choice. People can stop anytime they want,” “People that have mental health issues are dangerous,” and “People that are addicted because they have low character; they are all liars and thieves.” These societal beliefs have increased feelings of shame leading to isolation for vulnerable people, and until recently, has discouraged efforts to thoroughly dig into the roots of these issues to find solutions. If a problem is misunderstood and common symptomatic behavior is demonized, it is not surprising that services needed to help individuals with these disorders would historically be limited and blatant, intentional barriers to access might be tolerated even by legislators charged with the care of their communities.
California county systems of care are designed to operate according to a uniformed standards and practices for mental health and SUD treatment and to opt all eligible people into the appropriate services. Admission to eligible services under Medi-Cal is based on “medical necessity,” which means having at least one qualifying diagnosis from the Diagnostic and Statistical Manual of Mental Health Disorders 5th Edition (DSM-5). In addition, the American Society of Addiction Medicine (ASAM) criteria is used for level of care placement for SUD treatment. These are uniform standards. However, private insurers are not held tightly to the use of industry standards and often use their own criteria which can be confusing for biller’s and impact access. In addition, insurance carriers are not required to utilize all levels of care available under ASAM for SUD. Utilization review specialists that work for private insurers can deny access to care according to their organization’s definition of “medical necessity” or severely limit time spend in more expensive levels of care even when they have never seen the patient and the treating physician/clinician who assessed the individual deems a service “medically necessary.” These practices are not tolerated for other common health conditions which is why these appear to be discriminatory practices.
Behavioral health advocates have done a great job of bringing the high prevalence of disorders to light as well as the questionable practices of many private insurers. As a result, legislative movement has begun to swing in the direction of the consumer. The most recent example is Senate Bill 855 (Wiener, D-San Francisco).
According to The California Consortium of Addiction Programs and Professionals (CCAPP) SB 855 will increase access to mental health and substance use disorder (MH/SUD) care for the 13.4 million Californians enrolled in state-regulated plans who, too often, have coverage arbitrarily and wrongfully denied by insurers. Coverage denials based on insurers’ determinations that MH/SUD care is “not medically necessary” are a primary way that insurers limit access to MH/SUD care and undermine the promise of both the federal Mental Health Parity and Addiction Equity Act and the Affordable Care Act. These inappropriate medical necessary denials for needed MH/SUD care frequently limit the treatment patients receive to only late-stage crisis care and short-term symptom reduction rather than treatment for the underlying chronic condition. By putting in place common-sense rules that require insurers to follow generally accepted standards of mental health and substance use disorder care, SB 855 will now significantly reduce these inappropriate denials and increase access to early treatment that addresses the patient’s underlying condition (2020).
As someone in long-term recovery from SUD and who lives with mental health issues, I am glad to see the State of California is holding insurers accountable to the consumers that they are supposed to serve.
Michael Prichard M.S., LAADC, ICAADC, currently serves as Vice Chair and Legislative Chair for the California Consortium of Addiction Programs and Professionals (CCAPP). He holds a master’s of science in addiction counseling, is a Staff Analyst in SUD Prevention for Fresno County Department of Behavioral Health, and is contracted trainer for Central California Training Academy through California State University, Fresno Foundation.