Many of the inquiries “Ask Wendell” has received pertain to mental health and behavioral issues. Until recent years, insurers in general provided little or no coverage for treatment of mental illnesses. It took an act of Congress—literally—to change that. The Mental Health Parity Act (MHPA), which became law exactly 15 years ago today, requires that annual or lifetime dollar limits on mental health benefits be no lower than the dollar limits for medical and surgical benefits offered by a group health plan.
Because insurers were finding ways to get around the law’s requirements—they were, for example, limiting the number of provider visits and the number of days they would cover for inpatient psychiatric hospitalizations—Congress amended MHPA three years ago by closing some loopholes. Nevertheless, many Americans with mental health problems still face more coverage limitations than those with physical illnesses, as the letter below illustrates. If that is happening to you, fight back.
My son was diagnosed with severe psychotic depression. He is slowly recovering, but he still has a way to go and does best when he can see his psychiatrist four times a week. Anthem Blue Cross will only pay for two sessions a week. We've tried to fight this, but they won't budge, saying their psychiatrist has decided my son's condition only warrants twice weekly sessions. Their psychiatrist has never met my son, so how can they justify this judgment call? Is this legal? How can they justify this when there is no longer a cap on the amount of treatment? Is there any way we can fight this?
What your son is experiencing is a practice in the insurance industry known as "partial denial," and it very possibly could be illegal. As a first step, you should initiate an appeal right away. But don’t stop there or even wait for the results. Become a “squeaky wheel.” Insurers hate squeaky wheels. Anthem executives very possibly will agree to the number of sessions your son’s psychiatrist believes is necessary when they realize you will squeak long and loud if they don’t.
You should have two or three levels of appeal available to you: one with your health plan and at least one with an outside review company.
If you lose the first round and have to request an outside review, do so promptly and notify Anthem executives in writing that you are giving them seven days to respond or you will contact your state’s insurance department.
Be prepared to do just that. If you file a complaint with your insurance department, send a copy of it to the benefits manager where you work (if your policy is through an employer) and to Anthem bigwigs.
Doing all of this will send the message that you are not going away.
It is not clear from your email where you live. If by chance you live in California, Anthem’s biggest state in terms of enrollment, your letter-writing campaign should target Pam Kehaly, president of Anthem of California, and Jeff Kamil, the plan’s chief medical officer. If you live in another state, write to the appropriate state plan president and chief medical officer.
Regardless of where you live, also send a copy of your correspondence to Angela Braly, CEO of WellPoint, Inc., (Anthem’s parent company) and John Cannon, WellPoint’s general counsel and chief public affairs officer, at 120 Monument Circle, Indianapolis, IN 46204. For good measure, you might also send copies to one or more of WellPoint’s board members. You can find their names on page 31 of the company’s annual report.
The reason I suggest writing to the executives directly is because, even though they don’t publicize it, almost all insurers have special high-level review units that review and respond to what they call "executive appeals" or "executive grievances."
Copy your state’s top insurance regulator(s) in all your correspondence (and indicate you are doing so at the bottom of your letters to Anthem/WellPoint). California is unique in that it has two regulatory bodies: the Department of Managed Health Care for HMO coverage (Brent Barnhart is the director) and the California Department of Insurance for other types of coverage (Dave Jones is the commissioner). Both departments have robust consumer complaint processes and take their roles very seriously. The DMCH has an expedited appeal process that leads to review by a neutral independent third party.
The California regulators—and those in many other states—do a pretty good job of sorting out the issues and assuring that complainants are treated fairly and in accordance with the law and within the terms of their benefit plans.
You might also consider contacting your state legislators and members of Congress and one or more local newspaper or TV reporters. I can almost guarantee you that you will get special consideration if a lawmaker or reporter contacts Anthem/WellPoint about your complaint.
It’s a shame you might have to do all of this, but it might be well worth it. Insurers know most people will not be squeaky wheels, which is why they often get away with breaking state and federal laws and regulations. But statistics show that there is a better-than-even chance you will succeed if you persist.