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Troubles mount for families of opiate addicts when insurers won’t pay for treatment

When a health insurance company canceled a 48-year-old man’s medicine to weaken his dependence on heroin, he made a desperate call to his 77-year-old mother. Now she is paying $130 a week for his Suboxone prescription.

A teenager hooked on opioids has been told that his health insurance refuses to cover the full stay for his inpatient treatment. His parents have shelled out thousands of dollars.

Then there is Avi Israel. His son Michael committed suicide five years ago after the family’s health insurance refused to pay for his stay at a detox facility.

At a time when fatal heroin and opioid overdoses have risen to unprecedented rates – 10 suspected opiate overdose deaths a week in Erie County – many area families complain that health care insurers are denying coverage for loved ones seeking medication and inpatient treatment for their addictions.

Many of these denials violate state and federal laws requiring equal treatment for addiction and other mental health illnesses, according to the families of those who are addicted.


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A State Attorney General’s report from 2015 backs up that claim. Excellus Health Plan, based in Rochester, improperly denied 2,700 claims between 2011 and 2014, including several dozen from Univera Healthcare – for inpatient drug treatment and eating disorders, according to the report from the AG’s Health Care Bureau.

Excellus, which operates as Univera Healthcare in the Buffalo area, agreed to pay $500,000 to the state attorney general’s Health Care Bureau after an investigation of how the company handled requests for inpatient addiction treatment services.

Other health insurers across the state also have been ordered to reimburse a total of $1.2 million for denied treatment that their members paid out of pocket.

State officials say the penalties are part of a process to make sure health insurers obey the state laws.

For some families, the changes are not coming fast enough, and that is why they are speaking out in advance of a meeting later this month to discuss their complaints against insurers and possible legal actions against the companies.

Health insurers, however, offer another perspective.

They say they are doing everything they can to help those enrolled in their plans receive appropriate treatment. They also say they follow criteria approved by prominent medical organizations and New York State for determining levels of treatment.

And the insurers say their decisions are based on an individual’s needs, not the costs.

But they also point out that addiction treatment can run into the tens of thousands of dollars for a single patient. What’s more, it is not uncommon for addicts to relapse several times. Those repeat admissions compound the costs, whether for less expensive outpatient programs or more expensive term inpatient treatment.

At the same time, escalating health insurance premiums and copayments have evoked cries from many people to keep a lid on the ever increasing costs that have eaten away at household budgets.

Advocates for treatment, nevertheless, say that the best way for treating addiction is through readily accessible health care, rather than waiting for addicts to either die from an overdose or run afoul of the law and enter the criminal justice system. Once there, judges have the option of ordering individuals into treatment, and the costs then are often covered by Medicaid, a taxpayer-funded program.

The advocates also point out that many individuals became addicted after being prescribed opioid pain medications for legitimate injuries, unaware the medications were highly addictive.

Frustrated and angry

Donna Rose says that on three occasions, her teenage son was informed that their insurance company would not pay for his stays at inpatient facilities.

Twice, she and her husband wrote checks totaling more than $13,000 to keep him in treatment.

On a third occasion, when insurance refused to cover the fourth week of a 30-day treatment facility’s program, the son left, refusing to allow his parents to pay yet again.

Rose says the State Attorney General’s Office is reviewing one of the denials and she may seek a reimbursement from Excellus.

“I attended a closed-door meeting in Buffalo on April 12 when Lisa Landau, the chief of the Health Care Bureau, presented the 2015 annual report that focused on the opioid epidemic,” Rose said. “I had the opportunity to speak for all of the families who have experienced this nightmare of insurance denials. I was outraged when I later read page 10 of the report.”

Under the heading of “Enforcement Actions” on that page, the report provided details of the settlement reached last year with Excellus for refusing inpatient treatment costs for 2,700 members. The company was ordered to notify those individuals they could appeal the denials and receive reimbursements.

According to the report, 10 people so far have been reimbursed $55,000.

Even when insurance companies agree to pay for inpatient treatment, the companies often monitor progress and cut short the stay, Rose said.

When that happens, it amounts to a denial of benefits, she said, especially when treatment workers believe the patient requires more time.

“Insurance companies have all these ways of denying access to treatment, for example, a mental health evaluation that you pay out of pocket, if you have a safe place to live, your mom and dad love you and you have had no disruptions in your relationships over 30 days. Or you have just completed detox and you have no drugs in your system, therefore, you are not at risk,” Rose said.

Excellus officials, in a statement to The Buffalo News, said they adhere to state and federal parity laws and follow a protocol for determining the course of treatment that is based on criteria “developed and updated annually by a national, reputable third party.”

Two widows’ struggles

Judy Capodicasa and Colleen Frey are widows and in their late 70s. Both worry about their sons, who depend on Suboxone, a prescription medication that reduces the urge for heroin and other opioids.

Capodicasa, 77, says a pharmacist last month told her 48-year-old son, a recovering heroin addict, that his Medicaid managed health care plan had stopped paying for his Suboxone.

“He called me. He was hysterical,” she said. “I just said I’ll pay for it until we find out why they are not. It’s $130 a week, and I go to the pharmacy and pay. I’m a retired teacher and don’t have that much. He has been in inpatient many times, but lately he has been very stable with the Suboxone.”

Capodicasa says she is having trouble contacting the insurance company.

“I was told it was Medco by the drug store but I haven’t been able to reach the company. All I can tell you is the prescription is not being paid by the insurance,” she said.

For Frey, 79, there’s a different twist with her 46-year-old son who will soon lose his Suboxone prescription. His doctor – federally certified to write Suboxone prescriptions – has notified him that his insurance, as of June 1, will no longer pay for the medicine.

“That’s because the doctor has not renewed his contract with Medicare and my son is on Medicare because he is disabled,” Frey said.

He became addicted to prescription opioid painkillers when he was being treated for an autoimmune disease that calcified his joints, the mother said.

“I’ve called 15 different doctors who write Suboxone prescriptions and accept Medicare, and they all have waiting lists. I don’t know what we’ll do. My son also receives Medicaid, and I called a couple Medicaid doctors but was told by them that we would have to pay $150 to $200 a visit,” she said. “I’m recently widowed and concerned about my son’s future. When I’m not here, what will happen to him?

“I want to get this settled. I’m hoping something good happens by June 1.”

At their parish, St. Joseph University Catholic Church in Buffalo, Frey and Capodicasa sought signatures Sunday for a petition to alert public officials of the insurance problems individuals in need of Suboxone are experiencing.

Meeting in May

Not all health care plans are alike, said Julie Snyder, spokeswoman for BlueCross BlueShield of Western New York.

“I get very concerned when we get lumped in with other insurers. We routinely place our members at Horizons’ inpatient treatment,” she said, adding that BlueCross BlueShield has no restrictions on paying for Suboxone.

As for how treatment is determined, health insurers and physicians are required to comply with state guidelines, she said. “We are on the Erie County Opioid Task Force and at the table supporting innovative ways to address the issues, including Suboxone,” Snyder said.

Avi Israel, though, described how BlueCross BlueShield rejected his son’s treatment after he became addicted to pain medications doctors prescribed to him for Crohn’s disease.

“Michael got rejected by BlueCross BlueShield. The reason was there was no doctor at the facility 24 hours at a time. … Nobody has a doctor physically in a facility 24 hours. They have them on call,” Israel said.

Israel says public awareness of the rights people have when it comes to health insurance drug treatment has not made much progress since the death of his son five years ago. He urged parents and loved ones of addicts to attend a meeting 6:30 p.m. May 17 in the Stuart Steiner Building at Genesee Community College in Batavia to discuss the possibility of legal actions against health insurers.

“In many cases, insurance companies have subsidized the addiction by paying for the prescription medication and then refuse to pay for treatment,” Israel said.