– [Dave] Good day and welcome
to Learning Thursdays. I am Dave Cruder with the OASAS Learning and Development unit and your
host for today’s presentation. Today’s presentation is
titled know your rights for substance use disorder and mental health treatment and insurance. Our presenters today are Rob Kent New York State OASAS General Counsel, Trisha Allen New York
State OASAS Senior Attorney and Stephanie Campbell Project Director for the Substance Use Disorder and Mental Health Ombudsman Program. They will be joining us in just a moment. First a word about Learning Thursdays. Learning Thursdays are offered
to addiction professionals as a free learning opportunity with the goal of improving
the knowledge and skills of the New York State substance
use disorder workforce. We strive to improve
the lives of individuals needing prevention, treatment
and recovery services. A goal of Learning Thursdays is to support the professional development
of the treatment prevention and recovery workforce. We do this by offering
regular presentations that are relevant to today’s substance use disorder
treatment professional. As always if there are
any questions, comments, or suggestions, please
feel free to contact us at the Learning Thursdays mailbox. You can use the same mailbox
to express an interest in providing a future
Learning Thursdays program and now it’s time to
start the presentation. Welcome to our presenters. – Hello, I’m Rob Kent. I’m the New York State
OASAS General Counsel. We’re gonna talk to you
today about insurance rights and access to treatment as it relates to coverage for insurance. Joining me today– – Hi, my name is Trisha Allen. I’m one of the internees in
counsel’s office at OASAS. I work with Rob Kent. – And I’m Stephanie Campbell, I’m the project director for
the SUD and mental health ombudsman program
otherwise known as CHAMP. – So questions that come in as it relates to this presentation you can send to the email address on the slide that we just showed. So we wanted to lead in
you know we could make this a very blunt conversation
about insurance law and appeal rights and
all kinds of acronyms we’re government we love acronyms. But you know more and more as
we’ve worked in these issues and we wanted to make this point you know overdose does not
discriminate stigma equals death. We didn’t create that, we use it. Actually it has origins way
beyond the HIV/AIDS epidemic but silence equals death
was what was used there. What we’ve observed as
we’ve been addressing access to treatment, insurance
coverage as it relates to the opioid epidemic
so much of what impacts is not just the laws and the
rules but also the stigma associated with the disease. The stigma impacts the
way the laws were written which we’ve been trying to rewrite. It also impacts people being
willing to access treatment and insurers providing
coverage for the treatment while people are seeking it. So is that as a lead in we’ve
spent a great deal of time in the last number of
years under the leadership of Governor Cuomo and our Commissioner Arlene Gonzalez Sanchez trying
to eliminate the barriers to accessing treatment for
those with public insurance be it Medicaid, Medicare
but also private insurance, commercial insurance. Just need to make a couple
points though as we move forward and which one of them is the following. So government acronyms ERISA. There are insurance
policies that are protected by a federal law called the
ERISA and I think we go into it a little more detail as we move forward. So just so people understand context about half of the insurance policies in the private insurance market
written in New York State are not protected by New York State law they’re protected by federal law. So with that qualifier as we go through what we’re going through today the laws, the appeal rights, everything
that we’re gonna talk about today relates to those
policies that are covered and protected by New York State laws. The other set of laws as I said ERISA, protected insurance plans
which we will explain we can’t impact those insurance
policies unfortunately that’s something the federal
government addresses. So stigma. Mental health stigma leads
to feelings of shame, poorer treatment outcomes. These are research studies,
I’m not gonna read this stuff. I’ll explained to you. Stigma impacts people accessing treatment and it impacts people receiving coverage and providers being paid for
providing that treatment. It still was a major issue. We could do a separate Learning Thursday and we’ve done those and
we’ll do more in the future explaining how we’re trying
to break down the stigma. But this program is
intended today to focus in on understanding coverage
rights for private insurance in Medicaid and so as a
menu in a lead in today and I’m gonna turn a lot of
this over to my colleagues who work with me on these things. We’re gonna explain
some of the definitions that apply in this world. Talk about where the New
York State laws do apply. What is covered by commercial insurance? What is an in network provider? What is an out of network provider? What’s utilization review? What is an appeal process? What is the ombudsman program which Stephanie just introduced herself as our project director. Some common questions and resources. I would encourage all of you
watch this video, share it, we’re gonna post it on our Web. It’s free, it’s available. The more we can make people understand what they are entitled to when they have a private insurance policy
the better off we all are. The more people who are gonna access care and obviously the easier
it is to help people get to a point of recovery in their lives. So with that T. do you wanna talk about some of the definitions and– – So the thing that I will
say that is most important when you’re looking at insurance coverage is really understanding the
details behind your contract. Typically you have a document that you get from your insurance company that lays out what services they’re gonna cover, what steps you need to
take in order to access a particular provider or type of service. So that document really is
very important to read through and understand however I also recognize that reading an insurance contract is probably not an excellent
way to spend a Saturday. So a couple of brief
definitions and then I’ll cover a couple of other items
and feel free to chime in if I miss anything or if
you wanna add anything. And the first thing to
know is when you say that something is covered, all that means is that your insurance
company has agreed to pay for that service. If you’re talking about networks, a lot of insurance policies is a agreement between an insurance
company and a provider saying that that provider agrees to accept that insurance company and the payment that they’ve agreed to
for a particular service so that provider is now in the network with the insurance company. Another key word or topic
is utilization review. So this is simply the process
that an insurance company has to look at a service and determine if they’re going to pay for it. So this may be what’s known as a medical necessity determination which is a common word that you hear when you’re seeking services
but they’re trying to determine if the service was appropriate
for someone to receive. And then appeal. So an appeal is a process
that you as the consumer, the person who has a contract
with the insurance company or somebody that you ask
to do so on your behalf like your provider, they can
go to your insurance company and ask your insurance company
to re-look at a decision to not cover a service. So if you ask for outpatient treatment and your insurance company says no, you are somebody that you designate can go back to the insurance
company and just ask them to take a second look. And we’ll go through,
there’s an entire process and there’s quite a few
timeframes to be aware of but that’s just an upper level
definitional starting ground. So a couple of things to be
aware of on the federal level. There are two laws that were enacted. The Mental Health Parity
and Addiction Equity Act or MHPAEA for short or parity
as it’s more commonly known was a federal law that was passed in 2008 and I think they’ve done
a few regulatory updates. I think 2013, 2016 maybe most recent. You hear parity said a lot. So parity is applicable
to insurance companies and all it means is the
insurance company has to provide coverage for if they provide
coverage for mental health and substance use disorder services or behavioral health services. They have to do so in a way
that is on par or similar and comparable to the way they treat medical surgical benefits. So for example if I were to go to a doctor who was a specialist for my foot, I hurt my foot and I go
to a doctor for my foot and there’s no prior
authorization for that. I just walk right in,
I don’t need a referral or anything like that but then
on the SUD side of the world maybe you need to go see your
primary care doctor first before you can go to an outpatient visit. And you have to have a prior
authorization conducted and they have to review every single day that services are provided. That is a very blatant
example of how the coverage wouldn’t be provided in
a way that’s comparable because the requirements and
the structure set up around the SUD benefits is so much
stricter than it would be on the medical surgical side. – But it’s a floor so in other
words a lot of the things that we’ve done in New York State that impact New York State
policies we’ve exceeded parity. – [Trisha] Exactly. – Eliminating prior authorization,
other things like that so parity is wonderful
that there’s a minimum but states are permitted
to exceed the parity law. – [Trisha] Exactly. – Great – An additional change that came about was the Affordable Care Act. So this was in 2010 I wanna say– – [Rob] Yeah, I think so. – I might be wrong on the year. So essentially it just said
that these specific benefits are essential health benefits
that have to be covered. SUD was included in there, it
also references medications and the Affordable Care Act
actually speaks specifically to a naloxone which we’ll get into later about why that’s so important. And how you have to as an
insurance company cover naloxone because it’s the only formulation or type of that medication
that is currently in existence. So alright first question you need to ask when you’re talking about
your insurance company is my policy even covered
by New York State law? Rob mentioned this earlier. A lot of insurance policies aren’t because they’re issued by other states, they’re issued by a
specific like ERISA plans who are not subject to New York State law they’re actually stuck a
subject to federal law. So there is a website that you
can use that you can look up and determine whether or
not the insurance company is regulated by New York State. So I’ve included the web
link on the presentation and if you go to that
web link in and type in the insurance company name or just type in the type of insurance it can pull it up. So this is what I was speaking to earlier. There are two circumstances
where a New York State laws would not be applicable. The first is self funded or ERISA plan. So these are Employee
Retirement Income Security Act, that’s what ERISA means
and these are employer or employment group designed policies. They kind of as a group
set their benefit package and they also kind of determine what services will be
covered to what extent. They set their own standards
and they are subject to federal law not subject to state law. – So you mean if I’m a farmer I’m gonna have a different insurance plan than if I were a banker?
– If you were a farmer? (Trisha laughs) – Not necessarily. So typically speaking a self funded plan is more like a larger group plan or I think if you look at
like I’m gonna say Acme because I don’t wanna name
a specific company (laughs). But say you have a large
company that’s in– – [Rob] Like a multi-states. – Yeah multiple states so New
York, Connecticut, New Jersey, Florida you know– – Well we were not gonna say, we would say something else like – Acme.
Like Markwall. – But right actually I
don’t know which state their policies are written
in the laws of that state apply to those insurance policies regardless whether you live
in the state it was issued or not but you’re covered by it. – [Stephanie] And that’s helpful. – Yup so when you talk about
self funded or ERISA plans the other thing I will
note is for the plans that are regulated by New York State a lot of what you’ll
see is Anthem or Fidelis you know common insurance
companies that we hear about in New York State. Instead it’s actually the
employer who will manage it or they might have a third
party administrator manage it but it’s not an actual insurance company who’s taking on the risk paying the claims that kind of thing. – [Stephanie] So how do you know if you have that third party? – You have to ask. You really have to do
a little bit of digging to try and figure out what
it is that is applicable. I will note that there
is a resource available for ERISA plans at the federal
level when you have concerns that you can look into, I think it’s the employee
benefit services. They can actually assist
you if you have any concerns about a claim or maybe the
treatment that you’re receiving under the ERISA plan.
– The most important foundational thing is that
contract you talked about even though it might
be very tedious to read it explains everything they cover and all the process they use
to determine whether or not you’re eligible to access
a benefit they might cover. – [Trisha] Cool. – [Stephanie] Okay so what do commercial in New York State plans cover? As a result of legislation
which Rob mentioned earlier the federal level efforts as well, there are some basic benefits. Inpatient and outpatient
services for both always, sorry substance use disorder services and mental health services. I’m apologizing now cause I’ll
probably mix SUD and OASAS up a lot but they are covered services. Another thing that I will notice is that there is no denials for
preexisting conditions. I think that’s something
that’s really important especially in our world to
just throw that out there and make it very clear. If you get a notice from
a New York State plan that something’s not covered
because you had it before or you got the insurance you
really need to bring that to the state regulators attention which is Department of
Financial Services in this case. Okay so we have done a lot of work around the SUD world to ensure that people
have rapid access to care so I’m gonna break this out into a couple of different parts. Bedded care which includes
detox, inpatient rehabilitation and then some residential care so that would be for our 820 services, stabilization and
residential rehabilitation. And then also part 817 RRS
wise those are bedded services that are covered and we
also provide for access to those services rapidly. So if you are in New York State, you are covered by a New York State policy and you are seeking bedded
care if you go to an in state, in network facility you
have immediate access without prior authorization. And provided your program
determines that you’re appropriate for that level of care and communicates with your
insurance company within 48 hours they are not able to do
concurrent review for 14 days– – So they have to communicate
you’ve been admitted. – Yes. – They don’t have to seek
permission to let you come in or to have you stay. They’ve used a tool which we’ll
talk about that we created. – Yep. – You’re appropriate
for that level of care, you can go in immediately and you can stay there
for a period of time. Well ultimately it’s for as
long as you medically need it but there’s a process
that we’ll talk about. – [Trisha] Yes. – What if somebody says that I could go or my loved one could
go to a place in Arizona or Pennsylvania? – So you could, you absolutely
could go to Arizona. What I would say is we
don’t live in Arizona so– – That’s true. – [Rob] We don’t know anything
about treatment in Arizona. – That’s true too. – We don’t regulate
Arizona treatment programs. – And the argument that you’re gonna have with the insurance company
about coverage for services provided in Arizona that
discussion is gonna look a lot different than what you would have if you were to seek
treatment in New York State. Part of the provision that we have is if a program admits you to care and they believe that
you’re appropriate for care, you stay there for as long
as it’s medically appropriate but there’s no concurrent
review until the 14th day should you stay longer than that– – [Rob] So concurrent
review what does that mean? – Sorry so concurrent
review that’s essentially where the insurance company is saying you are currently receiving services and we are looking at those
services do to determine if you need any more. Prior authorization is
where they’re looking before you get any services
to determine whether or not you should have access to them. – So an important distinction then is that as you talked about in state
so if you go to Arizona these rules we’re talking
about even though it might be a New York State insurance
covered policy don’t apply. – [Stephanie] Ah. – Because we don’t– – So you don’t mind not
get coverage anyway. They could make the case that– – Well it would most likely
as well are they in network or out of network? They’re probably out of
network so you’re accessing so the first question would be do you have out of network coverage
in your insurance policy? And then it could be subject
to prior authorization, immediate review or a
review every other day and significant copays usually. It varies but we’ve seen
everything from you’re gonna pay 20 to 30% of the cost. The other key component
is if you’re in network the insurance company
has settled on a price they will pay you for the services not just that they cover the service but what they will pay for those services. If you go out of network
including out of state they get to charge whatever quote unquote their reasonable usual and
customary cost might be. We know of examples where that could run into the six figures. – Wow. – And you would owe 20 to 30% of that. – Wow. – The final point that I will make is with all of the provisions
that we have that allow for immediate access to
care there are limitations on the impact to patients. So if a provider determines
that somebody is appropriate for care and the insurance
company disagrees the dispute is between
the insurance company and the instate and network provider. There’s a provision in there
which specifically says that the patient has held
harmless from those costs, that is not the case in our
Arizona or any other state. – So that to maybe expand
on that a little bit. What that really means is you went to a bedded treatment
program in New York State on a New York State policy
covered by our laws. The provider determine front
end it was medically necessary using our tool, you went
in, you stayed for 20 days. The insurer can do what’s
called a retrospective review. They can look at everything
after the fact retrospectively and they could say you know what? As of day 11 you didn’t need to be there so days 12 through 20
what used to be the case before we enacted these laws
was hey you Mr. Consumer and your family you owe us
for days 11 or 12 through 20. When we changed these laws to
allow immediate upfront access and tried to balance all
the different interest we said to the world days 12 through 20 are now a fight between
the appropriate parties which is the insurance
company and the provider and the family is held harmless right? So. – So the next point that I did wanna make to kind of loop onto that
is we did similar actions for outpatient care that
happened just in this past year. The no prior auth or concurrent review is for the time period
of the first two weeks of outpatient care not
to exceed 14 visits. So there is that ability to
get in, have an assessment, maybe talk to a peer, see
what it is that you need but the outpatient program
and the patient have time to really understand
what the patient needs, get into a rhythm and go– – And that’s been the whole point is. When we enacted these laws
over the last four years the basis for them was the following. The governor created a task force, the lieutenant governor
and our commissioner went around the state. One of the things they
heard and this was in 2016 I’m sitting with my loved
one trying to get into a bedded program, an inpatient program or residential program and at that point there was prior authorization. So they might sit waiting
for the insurance company to make a decision about
you can go in or you can’t for six to eight hours. Now if you’re using substances
at about maybe our six maybe earlier of not having used waiting in the waiting room you’re gonna start to go into withdrawal. And what we found is they
either excuse themselves for a period of time to
eliminate the withdrawal or they go into withdrawal or what we heard far too frequently we’re leaving ’cause it’s not meant to be. So we wanted to eliminate
that and then we wanted a period of time for which the individual could be with treatment
folks getting better, stabilizing before you start interfering and making decisions about
whether they need to be there and for how much longer. I wanna make this point so
it’s 14 days in both bedded and outpatient and the
world has sorted defaulted to well you only get 14 days of treatment. That is not the rule, that is not the law. We said there’s no interference
for the first 14 days. We did not say that’s all you get. If you need 20 days,
you should get 20 days. You should get all the care you need that is medically necessary. The problem is the way our
world is sort of evolved everyone’s defaulted to 14 days which depending on the timing of this show which is why the governor
put forward in his budget for fiscal year ’19-’20 we
wanna extend that to 21 days. Because our thought is if
everyone’s gonna default to the easy which we made
14 days why not make 21 to give a person even that much longer to stabilize in treatment. So I wanna be clear with
everyone if you hear that from a provider where
they’ll only cover 14 days the response should be what I was told and I watched this video
and it said I’m entitled to all the care I medically need. – [Trisha] On the flip
side of that just to– – [Rob] Yeah. – I will note that there are certain cases where you may not be
appropriate for 14 days. There are definitely
certain levels of care where the intervention is a lot shorter so just because the law says
14 days just like Rob said that doesn’t mean you’re
going to get 14 days. It may be shorter, it maybe longer. The other thing I will
add is that 14 day clock that we’re talking about is
specifically related to the time when an insurance company
can kind of intercede and discuss with your provider what services you’re gonna get. But that clock starts or
restarts I guess you could say when you go to the next level of care. So say you start at a detox
unit you may be appropriate for three days in a detox
unit and then be connected to an inpatient or residential service. So the clock would restart
when you got admitted to the inpatient or residential service and then you would have a
discussion with that provider. They would be conducting
a clinical review of you to assess your appropriateness
for that level of care every couple of days and
periodically they would be talking with your insurance
company to just make sure that everybody is aware
that you’re in the program. Maybe they’re letting them know what kind of progress you’re
making and also we say that discharge planning starts the minute you walk into a treatment program. Because it’s our absolute expectation that our providers are going
to be able to connect you to the next level of care hopefully in a completely seamless manner. So the next topic medications. – [Rob] Yeah. – Oh one thing I did wanna
point out family visits. So just– – [Rob] You mean like
treating in the family? – Yes. – For a person who’s in
treatment themselves. – Yes. – Do they need to have an addiction? – No. – You can treat them? – Yes. – The law protects that. – 20 visits provided well so
the insurance company allows for 20 family visits– – Whether or not they have
– When they’re covered – a substance use disorder.
– under the policy. Whether or not they have
a substance use disorder. – Absolutely. – Because it’s a the family disease and we want the families to get better while the loved one’s getting better. – Absolutely. – And our providers by the way ought to offer you that benefit. – Absolutely.
– All of them right? – [Trisha] Yup. Finally medication. So there could potentially
be a difference in the future we’re not sure but for
right now there is currently no prior authorization for
a five day emergency supply of medication for maintenance
or detox medications for a substance use disorder
and then also access to opioid overdose reversal medication so that would be naloxone. One tip that we say is
to have the prescriber write emergency on the
prescription so that they are aware that this would fall under
the five day emergency supply. – And actually as T. was sort of hinting at the governor’s ’19-’20 budget proposal we want to bring parity
for medication access to what we’ve brought for
bedded and outpatient program. And we want the rule in New York to be whatever you might need bedded treatment, outpatient treatment or
Medication Assisted Treatment that you can get all of it without any prior auth or interference. So there is a proposal in this
year’s budget to eliminate the five day role because
we would eliminate prior authorization for
the appropriate forms of Medication Assisted Treatment. That already is the rule in Medicaid. – What about in the emergency room if someone goes in through the ER? – Different. – Different okay. – [Rob] Yeah. – That would be more I
believe that would fall more under the emergency
provisions or a coverage for emergency services and
there is currently in law a prudent layperson
standard for whether or not emergency services are
covered and emergency services are required to be covered I
believe under all contracts in New York State for insurance. – Okay. – So mental health coverage. I know we’ve talked a lot about addiction and parity covers both so
are there rules in New York for mental health or any kind
of protections above parity? – So New York is really
progressive actually. We passed Timothy’s Law
believe in 2006 maybe which essentially set almost
a standard for parity. I will say that we have some
work to do on the coverage of mental health services and actually as part of this year’s budget
Governor Cuomo has put forward a proposal to increase access. So that includes slightly
altering the definition for mental health to reference the DSM-5, the most current version of the DSM-5 and making it a little bit broader. Currently the language only speaks to biologically based mental illness so this would just allow
for a broader coverage. It includes a couple of
new types of practitioners I think nurse practitioners
is one of them so expands the universe of people that
you could have access to for mental health treatment. And we also added some state
level parity provisions to New York State law
to ensure that you have a clear understanding of the
network and you have access to enough information as a consumer so you can really decide
whether or not your policy is gonna cover what you need.
– So we’re tying to write parity protections into New York State law just in case. I mean we know our federal
government is very stable and function at a great level and so but just in case they
don’t we’re trying to build those protections into our own law. – Yup.
– You don’t have to comment. (Rob laughs) And Timothy’s Law just
so people understand I mean it was named after Timothy O’Clair who took his own life. He had a history of mental illness, he couldn’t get access
to treatment and he felt like that was his only choice
but it was really limited to a certain specific group
but it proceeded everything. It proceeded the federal parity and it was one of the first attempts to create some minimal set of protections. It was limited to a few
like biologically based mental health issues and the
governor’s budget proposal as T. talked about we are
seeking to update that with the current
understanding of the world as it relates to mental health so. So in network, out of network. We’ve been talking about that,
what does that really mean? – Okay so insurance
companies have requirements that they have to follow
about having essentially a minimum number of providers in the area where the consumer lives. For instance I’m gonna use a
non healthcare related example. I live locally so I have access to probably 12 different grocery stores. I have an aunt who lives in the mountains and has access to one
about 60 minutes away so same thing here, right? When you buy a policy
and insurance companies just have to make sure that
you have access to providers or have a network of providers,
people who have agreed to provide services to
insurance companies consumers or covered lives at a specific level. So one of the standards
is 30 minutes, 30 miles. So you have to be able to access services within that timeframe. So if a provider is more
than 30 minutes away it’s probably not an adequate
network or 30 miles away. – [Rob] Now the federal parity law is that that’s what requires
as adequate network? – So federal parity again is
a floor and it just requires that the network that
they have and the process for adding providers into a network on the behavioral health side is the same or at least not more restrictive
or onerous than it would be on the SUD or the medical surgical side. – ‘Cause as we talked about
a network provider has agreed to have a contract with
the insurance company and they’ve agreed to the
services they’ll cover and provide and the rates
they’ll be paid for doing that. – [Trisha] Exactly. – So what’s the out of network and? – (chuckles) Anything
that’s not in network. No so out of network would
be a facility or a provider that does not have an agreement
with your insurance company prior to you showing up at
their door saying I will treat any of the people that you cover. We used the example earlier
we referenced Arizona. – [Rob] Right. – There are laws in place
that provide for coverage of out of network or standards
when there’s coverage for out of network not
every policy has to provide out of network benefits. – Right so there you go right there. So first off you don’t just
have an automatic right to go anywhere if you
have private insurance and you might not even have
the benefit of being able to go to an out of
network where they’ll pay any part of that cost. – [Trisha] Yep. – How do you know though
if you have out of network or in network services? – So again your contract. Your contract is going to very
clearly state whether or not you have out of network
benefits and I will note that the contract language that you see for an in state policy, for a New York State regulated policy, New York State has something
called model contract language and this is actually applicable to both Medicaid and commercial. If you look on the Department
of Financial Services website there’s different language depending on if you’re talking about
a small group policy or a large group policy but
it’s pretty standard language and the state actually
looks at that language. So if you wanna understand
or see maybe a sample of what likely should
be covered and generally what the language would
look like you can find it. – [Rob] Okay. – Okay so (laughs) this
is a lot of information and it kinda gets at what we
were talking about before. Am I entitled to out of network benefits? The first question you have to ask is, does my policy even provide for coverage for out of network services? So if you get past that, yes great. Do they cover behavioral health services? Great if that’s a yes then you have to try and in the event that you
do need to go out of network and you know we recognize that
there is that possibility. Remember that the rules are different so there’s likely going
to be prior authorization. What you should always do is reach out to your insurance company
first and find out what your benefits are and ask them about in network providers. If you can’t get access to
that then ask them to help you navigate the out of network process. Insurance companies do have to
provide you with information so just be aware that they can help you. – But in with an out of
network if it’s covered there’s different kinds of copays which is part of your contract. – [Trisha] Absolutely. – They’re not subject
to a lot of the rules we’re talking about or the
protection that we’ve afforded so you really need to be careful. And not to complicate too
much but there are providers within New York who will not
be in every provider’s network so you could even stay within
state and still have it be an out of network situation. I’ll give an OASAS commercial. The one thing I would
say as it relates to that is any provider providing
SUD treatment services in New York State is
licensed by our agency and overseen by our agency. And we have a minimal set of expectations and plenty of enforcement
tools to make sure that those are followed okay great. – So if your insurance
company won’t cover care at an out of network facility
one of the key things that you need to be thinking about when you’re seeking coverage
for an out of network program or facility in state or what have you. You need to think about the justification for why you’re going there. Obviously if your insurance
company already has the network of ready, willing and able
providers there’s gotta be something that differentiates
the out of network program to justify going there. So that’s the hill you’re
gonna have to climb so to speak if you’re going through that process. And then you may have to get
a bill from your provider and then submit it to
the insurance company it’s an entirely different
claiming process– – [Rob] So they could even
ask you to pay up front. – Yes, absolutely. – And you get reimbursed by your insurer so you might be out of pocket
and there’s no controls on the price ’cause there’s no contract. – [Trisha] Exactly. – What if you have though like and I’m going back to the parity piece. If you have a bunch of
heart doctors in your area, in network but you don’t have a number of let’s say you only have
one provider in network. What happens with that? – So I think that that
would be a circumstance where you could use a justification for why it would be appropriate
for you to go out of network because it’s an insufficient network. Say they can’t get you in for two weeks and you’ve just overdosed
four times in a week that’s a pretty severe circumstance and that’s a pretty solid justification for the immediacy of the need
to get access to treatment. So that’s an indicator for the discussion that you would have with the insurance company.
– So we could use that as a reason to fight a denial. Oh, that’s great.
– Yeah. – So Trisha we talked
about utilization review. What does that means? – Okay so utilization review simply means that your insurance company
is trying to determine whether or not you need or
should have received a service. So there’s a couple of different ways that they can do utilization review. For SUD specifically
when you’re talking about determining an appropriate level of care we in New York State have
designated a specific tool that insurance companies have to use, that our providers have
to use and it is called lovingly LOCADTR or the
Level of Care for Alcohol and Drug Treatment Referral. So (laughs) we have a very
pretty graph shortly after this that you can see but essentially
this is a decision tree, it’s a web based tool that
allows a clinician to assess where somebody should be when they come in seeking treatment. – And I would just point
out with that so to give you sort of a quick history. In 2014 when we’d started enacting laws to try to address access issues in the midst of an opioid epidemic. We didn’t have a tool,
we didn’t have LOCADTR, we were just starting to create LOCADTR but what we said is we had a great concern based on what we were hearing
from families about the tools that were being used which
we weren’t able to look at. So we wrote into state law OASAS, our commissioner would get
to look at all the tools used by covered policies to make
level of care decisions and we had to approve them and it was a very enlightening experience. There’s concept of fail first
where insurers would say you have to fail first at outpatient before you go to a bedded program. We found level of care tools
that say you gotta fail five or six times before you
could get a bedded program all kinds of other very
fascinating things. We evolved to a point in 2016 where we had already tested
LOCADTR, we knew it worked and by the way it’s a web
based tool with takes like five to eight minutes to make a decision. Everybody uses it, it
is I think transformed the conversation in many ways,
it’s made it a lot quicker but now we moved in 14 to
just looking at everything. Now we re we make everybody
use LOCADTR, Medicaid, insurance companies,
Medicaid managed care plans, private insurers, our providers. And then for now for mental health the governor’s budget this
year is gonna start OMH where we started in 2014. They don’t have a LOCADTR tool but they wanna see the
tools that are being used and they wanna approve them
because they are convinced like we were and it bared
out that these tools are so fundamentally critical
to accessing treatment they ought to be fair
and clinically sound. So we’d like to say at the beginning we never fail first tool
we had to succeed first. You succeed where you go or
you you go where we believe you’ll best succeed
doesn’t mean you would get high levels of care automatically
you’d get what you needed based on a fair assessment. – [Trisha] And to kind of build off that. – Yeah. – I think at the end
of the day what we did when we moved to
designating a specific tool is we made a universal language, everybody was speaking the same language. Before when you were a provider
you had six, seven, eight, 12 different tools that you had to use depending on the patient that came in. It kind of reminds me
I remember being a kid and going to a doctor
and they asked my mom what insurance company I had so they could use the appropriate Q-tip. But you know that it kind
of changed the conversation for our providers because they
were no longer having to pick between which different
tool they had to use it’s all just one so– – It’s standardized. – Standardized exactly. Smoother okay. – Well the other thing people should know with LOCADTR as well was it’s housed in the Health Commerce
System which is part of the DOH electronic platform. We have every use of LOCADTR, it’s contained in that database
so we look occasionally and we need to make sure
that the tool is valid and remains valid but
we can also make sure whether the tool’s being used
efficiently and appropriately. – [Stephanie] And is
it used more than once? – So a LOCADTR is used initially
to determine whether or not somebody is appropriate
for that level of care but we also have what’s called
the Continuing Care module which is the tool that
our clinicians can use to essentially assess
whether or not a person needs to continue to stay in that level of care. – Cool.
– Great. – So a couple of no well we’ve
already covered all of this. Yup.
(mumbles) (laughs) So a couple of just distinctions between different types
of utilization review. The first is preauthorization
or prior authorization so this happens before you get a service. Concurrent review is while
you’re receiving the service. Retrospective review is
after you’ve left treatment the insurance company
will go back and look at the entire service
provided to determine all or what part in whole or in
part is clinically appropriate. Formulary exceptions and
step therapy overrides are actually something I wanted to hit on so a formulary exception. A formulary is a list of medications that your insurance company
has said we’re going to cover these medications and
they’ll set standards for if you need to talk to them before you can have the medication. Usually your pharmacy will
do the prior authorizations and when you get there
and pick up the medication they’ve already conducted
all the prior auth. Or they’ll set limits. You can only have 30 pills,
you can only have 30 days worth or 90 days you know whatever
standards they choose to set but there is a process, a
formulary exception process that allows you to
request the ability to use some medication that is
not on their formulary. So I just wanted to flag that ’cause I think that’s really relevant for our population.
– So like an example so buprenorphine which is one of the medications,
one of the three approved for treating opioid use disorder. – [Trisha] Yup. – There are multiple
versions of buprenorphine I will not name any of
them ’cause I don’t do any advertising for
pharmaceutical companies but we are aware of
circumstances where they may be on buprenorphine version A and
the company covers version B but the person’s stable on version A so their doctor could use
that exception process to say my client is doing well on A, I would like him to remain on A. – [Trisha] Exactly. – And that’s the process,
that’s what that means. – And if the doctor notes
that there is an immediacy or an emergency to
making this determination then it’s expedited or
it’s a quicker process. Now the step therapy override
that’s a little different. So that just means that
the insurance company has formulary and there’s tiers. So there’s preferred
medication so tier one and then tier two would be
medications that they cover but they want you to try
medication A first before you do B. Step therapy override process allows you to get to medication B without
having to try medication A perhaps there’s something in
medication A you’re allergic to or you’ve reacted poorly to it so medication B really
is more appropriate. – So really important
piece there in a plug for our sister agency the
Department of Financial Services so that everyone
understands another benefit of a New York State
covered insurance policy. No insurer in New York can issue a policy. It needs to be approved by the Department of Financial Services and that’s why they create
model contract language. They say to you as you’re
writing your contract for our review and approval
here are certain elements that absolutely must be in your contract and they do allow for
the tiering of drugs. Another component of their
oversight is they issue what’s called circular letters which are guidance regulatory documents that the insurance
companies need to follow in order to get an improved product issued in New York State. And they’ve recently said
that yes you can tier products but as it relates to
products for addiction and substance use disorder
you can’t set the products up and tier them based on price alone. There have to be other
clinical considerations, clinical justifications to
make those kinds of decisions. – [Trisha] Yep. – Great. I mean I think we’ve already covered this in terms of what LOCADTR is. Like I said we ultimately decided is the safest way of getting
to where we needed to get to which was quick clinically
sound decisions was you know we’re in New York we do our own thing. So there are other tools
that are out there, we don’t disparage any of those,
we got to where we got to. Our tool was written by clinicians, it’s reviewed frequently by clinicians, web based you know you don’t
need to be a doctor to use it but it guides you through
a series of questions which leads to a quick decision about the most appropriate
place for someone to get care. And that’s actually– – Yeah so those are the
different aspects of the LOCADTR this is what they’re looking at. So initially just putting in patient identifying information, they do a preliminary
assessment and then they look at you know is the person in crisis? What are the resources and
the risks that you have? Has the person had repeated
overdoses in the last week? Are they living in a home where there are others who are using? Do they have a supportive
family environment? So it’s just a kind of flow chart of what they’re looking at
and how they’re getting– – But so and actually that’s a really good where I talked about success
driven here’s what I meant. So as you’re going through
this process with the LOCADTR and the person’s had a bedded program but then you go through
it and you determine A, they have a job or
they’re going to school. They have a supportive environment, there isn’t other drug use,
they have a place to live. They’re stably housed, stably fed. They have all the elements
in place for them to exceed or to succeed excuse me
in a lower level of care so they would be appropriate
to go to an outpatient versus a bedded program
so there is no default that everyone ends up in a bed to start. The default is the place where
you will most likely succeed in treatment is the place
that you would be sent. – [Stephanie] It’s not
a one size fits all. – No. – It’s a really individualized
patient centered person centered. – Right, so you are preauthorization. We keep saying that, what is that? – [Trisha] Alright so this is the process that the insurance company is going to go to to
determine whether or not it would be medically appropriate for you to receive the service
that you’re requesting before you receive it so prior to. When you’re doing a prior
authorization process there are timeframes that the insurance companies have to meet. So if you make a request for a service they have to respond back in
standard time of three days but there are opportunities
for providers or for you to explain why it’s
critical that you receive a response sooner so then
it would be 72 hours. Court ordered treatment, I feel like that 72 hours is not right. – [Rob] But the most important things about preauthorization– – [Trisha] Oh it’s three business days I think is what it is. – [Rob] But if you are as
we talked so these really are more relevant if you
are using a non covered non New York State common policy– – If it’s an instate or out of state non network
– This is the role. This is gone. All these things we’re talking
about don’t apply in Medicaid and don’t apply in insurance policies covered by New York State law great. – [Trisha] I did wanna touch on court ordered treatment though because I think that’s relevant. So for the commercial side of the world there are circumstances
where an individual could potentially be
mandated or court ordered to go to treatment for a period of time. Just so you are aware
there is a special form, there is a special process
for you to reach out to your insurance company and
say that I have a court order or I anticipate I will
be getting a court order. Here is the document explaining that and they have to make a
decision about whether or not they’re gonna provide coverage for that court ordered
service within 72 hours so just be mindful of that. – [Rob] So concurrent review. – [Trisha] Yes. – What’s that mean? – So I’ve been in treatment for a while and then you know maybe
in current days world I’m appropriate for treatment. I’ve been there for 14 days. Day 15, my provider and
my insurance company have a discussion about whether or not it’s appropriate for
me to continue in care so am I going to get additional services? There is a response time
that the insurance company has to meet so that’s one business day. However one thing I will say is if you are in a bedded program we had special laws put in place and this is actually applicable
to any bedded service. If you are seeking care, more
care or looking to transition to a different level of
care they have to respond within 24 hours. If you’ve request it, they have
to respond within 24 hours. If they respond to that
request and deny it there’s also an expedited
timeframe for them to reconsider that decision to deny. We’ll actually get into
that when we do the– – So bringing all these things and trying to bring everything together. So you go to an in state OASAS in network covered program. – [Trisha] Yup. – You don’t have to get prior approval. You can go, there’s that 48 hour notice hey the person’s here. There is conversation that should occur it’s just they can’t
say to you on day seven you need to leave. On day 14 though they
can start doing reviews to say hey you should no longer be there but on day 13 if the program
and the person decides they really need 20 days,
they can request extension of the care beyond the 14th day. And if they get it wonderful,
we hope they should because if they use our
tool and that’s what it said that’s what it ought to be
but say the insurer denies. So then these processes
you’re talking about if you appeal that
denial they have to cover the additional care. You stay in the program
while they’re deciding about the appeal. – Yup the languages is that they pay
– And that they paid for that. during the pendency of the appeal. – And importantly
– So they cover it. the other protections we built in the family’s not gonna
be responsible for that. – Exactly. – And then that includes
staying in the program or even transitioning to another
program from that program. – Yup. – That all these protections
sort of build together to protect somebody is access to care. – [Trisha] Yup. – Great. – So I have a real quick question. What happens if you’re in
care and you’re being told by the provider that
you only get seven days or you only get 14 days? What do you–
– So our first question is, – what kind of policy is it? That’s one of the most important things that you should take away from this. Is it a policy covered
by New York State law that we’ve been talking about? Is it Medicaid managed care? If you hear that they’re wrong. With all these rules we’ve talked about there is no seven days. If it’s a non covered ERISA policy one written in another state it depends on what that contract said and so– – So it’s also the provider
that needs to be working with the person who’s in
treatment to kind of help navigate some of that as well? – So we’re gonna get into appeals but appeals can be asked for by the people in a contractual
relationship with the insurer which is the and the
family, the person in care both can appeal. We know of instances where
providers sometimes are reluctant to appeal but the family can always appeal which as you know which is
part of why we’ll talk about why you’re in the mix now
for some of these things. Because appealing these
decisions if everyone believes it’s the wrong decision is an
essential part of making sure people get access to
what they’re entitled to. So T. retrospective review, what is that? – The look back. So this is the– – [Rob] That’s permitted? – It is permitted. An insurance company can
look back to determine if care that was provided
was medically appropriate. This is actually what
we built in specifically with the bedded care
and the outpatient care because there was no prior auth. We wanted to kind of balance
the equities so to speak when we developed these laws. So a couple of things to be mindful of. Because it’s care that’s
already been provided it’s not quite as rapid of a
process when they’re looking at whether or not they’re
gonna cover services so they don’t have to respond as quickly it’s about 30 days. But the one thing that I will
say is if they make a decision and they haven’t talked to the provider then absolutely request a reconsideration or I believe it’s called
a peer to peer review in the insurance world. So that means that a clinician
from the insurance company and a clinician from the
provider will speak together. – So the law is that
every insurance company can do retrospective review on every episode of care provided? – So they are permitted
to do retrospective review but what I would say is remember we have the overarching standard the floor, right? Of parity so I would argue that if you have an insurance
company that is conducting retrospective review and
requesting significant volumes of information from a provider
for every single SUD claim and not on the medical surgical side that there would be a question if they’re really being fair.
– But so you mean they can’t say to the provider I want, so you had 20 people in
your program last month I want the full chart for all 20 people. – So the standard is that
the insurance company should only be requesting
additional documentation and not making a decision
where the obligation to pay is not reasonably clear
I think is the language within the statute. So it cannot be a default to
I’m always going to request a whole chart because that
would not be reasonable. You know presumably a broken
clock is right twice a day you know there can’t be (laughs) there can’t be every
single situation is wrong. – But to the point you made
it also has to be equal to what you do and from
a parity perspective whatever you do for for medical health, medical surgical you can do no worse on the mental health and addiction side. – [Trisha] Exactly. – Okay. – That’s the measurement okay. – So– – That’s the starting measurement. – That’s the starting measure. – Yes.
– Okay. – So we’ve talked a lot about medications and opioid use disorder. There are three medications by the way they’re the gold standard of
treating opioid use disorder and should be always in our opinion be the first course of treatment. There’s methadone, buprenorphine and there’s injectable long
acting naltrexone or Vivitrol I think is the product name
’cause there’s only one product. So there are a lot of rules. They’re expensive medications, they work but they can be expensive. – [Trisha] They can be yup. So this actually just
speaks to we talked about a little bit earlier the
tiering so different levels and it’s kind of just a flag really. So if you are on a
medication just be mindful that insurance companies do
change tiers from time to time or shift drugs from maybe tier A to tier B but they have to tell you first they can’t just surprise you. Typically you’ll get something in the mail so I would strongly
encourage you to open letters from your insurance company so you don’t get
– Can they do something – that surprised.
– like that like in the middle of your contract. – [Trisha] No, no, no because you’ve signed a contract, right? You’ve agreed to a term–
– So they’re bound just as you’re bound for that term or that contract so it’s like on a year to year. But so those notices you get about your insurance being continued– – Yes. – You should read those.
Double check it. Yes, very important. – ‘Cause they point out
the changes they’re making. – Yes, exactly and that also gets at the formulary exception process. So say you have medication
A and you know what? Next year we’re not gonna cover
it or maybe the brand name got more expensive you know that’s a relevant hot topic nowadays. It could be shifted to a
higher tier or maybe removed from the formulary in its
entirety so just be mindful that if that does happen
you have an ability to pursue an exception
process and have access to that medication.
– And one sort of key override point here is
these laws are important but as important is the
agreement that you’ve made with your insurance company. Understand we’re all well
two of us are lawyers and Stephanie has no choice
but to read contracts doing what she does. But they can be tedious
but that is the agreement. That is the understanding,
those are the rules for your relationship with
your insurance company and importantly and we’ll
get into it a little bit, it includes all the ways you
can exercise your rights. And so and we’ve said this to
folks and I wanna say it now we’ll probably say it down
the road in this conversation. The first question you’ll be asked by our Department of Financial Services if you wanna complain about
you didn’t get covered and you should have been
and they were wrong. The first question they will ask you, did you exercise your rights to appeal or to grieve under your contract? And if you answered no
they’re going to say to you there’s really probably
not much I can do for you ’cause effectively by
not appealing or grieving you accepted the decision by
the terms of your contract. Is that a fair– – That is absolutely a very
incredibly important point. – Great. – Okay so a step therapy
protocols that just means that the sequence you
get access to medications and formulary exception I
already touched on this one. – [Rob] So appeals. – [Trisha] Appeals,
everybody loves appeals is a favorite topic– – [Rob] Lawyers love appeals. – Yeah they’re great.
(Stephanie laughs) – [Rob] We’d prefer nobody
appeal in this world but that’s a whole different conversation. (Stephanie laugh) So we would prefer nobody have to– – Yes, that’s more accurate. Okay so essentially at appeal happens when an insurance company has conducted some sort of utilization
review so prior concurrent retrospective or you know
something with the medications and said no you don’t need this service. So your first step after
being like what do you mean? Is to say no I want you to reconsider so that’s what an appeal is. It’s asking them to look
at their decision again and decide hopefully in your favor though that is not always the case. There’s two different types to be aware of so the first is internal. So that’s where the insurance
company has somebody within their universe look at the claim and all the documents
that they have and decide whether or not they’re going to say yes or so overturn and say yes or keep the decision that they made. And then an external that’s where somebody who’s not associated with
the insurance company, it’s an external entity,
it’s somebody who is selected by the Department of Financial Services and you actually file your external appeal with the Department of Financial Services. They hire essentially the
external appeal agents. They look at all of the
information and decide whether or not the care
should have been covered. – So in that instance
they’re gonna hire an expert. So you can’t use a
gynecologist to make a decision about addiction treatment.
– No. – We have provisions in the
law for utilization review and also when you’re on the internal and external appeals
processes that the person making the decision has to
know something about SUD so either it’s going to be a physician– – [Rob] That would make them an expert? – Well– – Yeah, okay.
(Trisha laughs) – [Rob] I’m just– – They should– – But even those are the kinds of things you need to look at,
who’s doing the review? – Exactly and looking at
what tools they’re using to do the review. One of the things you’ll
see if you’re looking at an external appeal
decision is the materials that they used to make the decision. So if you look at the materials they used to make the decision and
LOCADTR’ is in there but ASAM is that’s a question that you need to ask and that is something you need to pursue because they shouldn’t be using just ASAM. – Just a quick anecdote on appeal. So when we in 2014 started enacting some of the new protections
that we did in New York we were being told by
the insurance companies well we win 80% of appeals. So then I said well my nature
by the way is I’m inquisitive, I think is the politest way
people have described it. So I said okay so was that all appeals? Well no that’s external. I said so let’s take a sample
of 10 cases on the internal how many are decided which way? Well on the internal appeals out of 10, five are decided in favor of each. So there’s five where
the person who was denied has now been approved. So I said it’s okay so there’s five left. So 80% of those five the
insurance company wins, said yes exactly. I said so five plus one
is six so 60% of appeals are decided in the
insured’s, the patients favor they said yes 80% so there’s the new math of the insurance world I’m sorry
I had to say that (laughs). So here we go. So we talked about who can request. – Yup. – [Rob] Who the person needs to be. – Quick question can you
have both the provider doing the appeal and the family member? – I mean there’s nothing
that says that they can’t. – Okay. – You know I think– – [Rob] You would certainly
help there working together. – Yeah, I would definitely
think that it would be better if they were working in
coordination with each other because obviously the program has a lot of the clinical information
and the insurance company is going to be looking for a clinical or medical justification for
why the service is appropriate and the provider is gonna
be the expert in that. – And the one thing I’d point out to just sort of amplify on that. If you’re in one of our
programs and in the moment your provider’s saying I’m
unwilling to appeal look us up, you can find us, you
should come and contact us because we would want
to have a conversation as to why that’s the case because we’re talking about appeal. So that means the provider said I believe they need more
help and it was denied and that leads to the appeals process but why aren’t they willing to appeal and that ultimately leads
into the Ombuds program. But it’s really critical. If you are denied and you don’t appeal you’ve effectively accepted
the decision that was made and you have no rights
to grieve it subsequent. – [Trisha] Exactly. – [Rob] Internal, we’ve talked
about the different kinds of what they are. – So these are just timeframes
that the insurance company has to hit but I would also note that in your insurance
contract it’s gonna tell you how long you have in order to ask them to reconsider something. And the other thing I will say is for a substance use disorder services we have a really expedited
timeframe for when the insurance company is
supposed to make an incision. But through all of these
there is an expectation that whoever is submitting the information get it to the insurance
company in a timely fashion otherwise they aren’t
subject to those timeframes ’cause they only have
to make those decisions within that timeframe within receipt of this information. – So that’s a really good point. So these expedited processes
which we put into place because somebody in crisis from addiction needs immediate decisions. They have to have the
information to make the decision so if you don’t provide the information they can delay the process
because you’ve not followed the steps you needed to
follow to accelerate it. – [Trisha] Yup. – So external we’ve talked
about the external appeals. I don’t know if there’s any piece– – Just one thing to be mindful of for the formulary exception process. There is I mentioned it
before but there is also an expedited process for the external same with inpatient SUD services. The external process
is an expedited process and again getting the paperwork in within the appropriate timeframes, making the request 24 hours prior to discharge that’s
all really, really important to hit those timeframes and be responsive because that’s what’s gonna entitle you to those protections. – So you, just real quick question. So for the internal and external, do you do the both of them– – At the same time? – At the same time?
– You could. – So you could. When you’re talking about internal appeals there is a process you have to go to so the first step is what’s
called a peer to peer review. So that’s where program
doc and insurance doc or rather clinician will
talk and they’ll either agree or you know in the sad
circumstances where they disagree that’s where you say okay
I want an internal appeal. So it goes to the official appeal process that they have to follow the
timeframes they have to meet. And then the outcome of that that’s called a final adverse determination
and that’s what entitles you to go to an external appeal and ask for this state designated entity to look at it with fresh eyes. But there are time
frames where you can talk with the insurance company
and say I would like to also pursue an external appealing and you can do both kind of in tandem. – But what if you have a loved
one and they’re in treatment and the provider is saying that they’re being denied
additional treatment. Like can they appeal and stay there or do they have to
leave or how does that– – That’s what we talked about we built those protections into the law. – When you’re in bedded treatment and you’ve met the 24 hour timeframe so you’re doing the
expedited appeals process. The rule is that the
insurance company has to pay for that care while the entire
process is being played out both internal and external. So the initial decision is within 24 hours and then the internal
appeal I believe is 24 hours and then the external is 72 hours. Provided everybody meets those timeframes I think it works out to like six days – And what that’s done
maybe but they did– the law what it has done a lot of times the insurer in many instances will say well let’s avoid the internal
appeal and just go immediately to an external appeal. But ’cause we try again we wanted to build these sort of balancing of equities in but the most important
piece ’cause what occurred prior to these laws is the following. Well you can’t stay here anymore or what was worse they’d
call OASAS and say well you need to keep them Mr. Provider. So the provider would not
get paid for providing care or the person would be asked to leave and leave if we didn’t know about it it’s just totally unacceptable. Providers not getting paid
and people not getting the care they need it’s why
we built these protections into New York State law. At some point by the way
I hope they’d be built in to the ERISA covered federal plans. Why are we still being denied? We still hear this so who wants to take this one on? – Well, I know that there’s
been a history of discrimination in the substance use world and the mental health world right? And so there were some
studies that were done I believe it was in 2015 was
it the Milliman study was done in which it was determined
that folks that had you know who were in need of substance
use or mental health issue had to go out of network
for care much more than the folks who were on
the medical surgical side. And then interestingly enough
providers were paid less than on the medical surgical
side so not only are you in terms of being a consumer
that you’re you know looking at stigma and discrimination but if you’re a provider similarly your rates of reimbursement
are gonna be different and those disparities only got worse. And I know that there
were a number of cases that were determined by the
New York attorney general at the time Schneiderman
I believe who decided that there was some
widespread parity violations. – [Rob] Okay so commercial
versus Medicaid. ‘Cause the parity
reviews have been looking at both commercial insurance and Medicaid ’cause Medicaid is also subject. If you didn’t understand
that Medicaid is subject to the parity law. – Yes and it used to be that Medicaid correct me if I’m wrong but people didn’t want to
use Medicaid, it was denied. The providers didn’t get
reimbursed from Medicaid and then all of a sudden there
was all of this legal work that was done by these people
in the Office of Alcoholism and Substance Abuse Services– (Trisha laughs) That started creating a
wrecking havoc for those folks and actually redesigned essentially the payment structure right? So that was great so then
Medicaid got reimbursed but then there were a couple
of studies the Kaiser study and the Weissman study
that were done that showed that on the commercial end there were these incredible disparities. And in fact for those of us who have fabulous commercial
insurance still there are when we try to get
services for substance use or mental health still
there’s some pretty egregious disparities in terms of what’s covered. And there’s data that
suggests that this is in line with as the epidemics
exponentially rose right that these denials
mysteriously also occurred. So there was this need then for consumers and providers to understand
what their rights were and then how to proceed with
getting those rights addressed. – So the solution, oh look at that. So we’ve been active. We’re active in New York. (Stephanie laughs) So do you guys wanna go
through some of the history? We’ve talked a little bit as
we’ve been going through this of things we’ve done in New
York to create protections that I dare say most
other states don’t have. – Well I know and prior to my coming here and working with you fine
folk I was an advocate in the substance use world. And I would go to national conferences and other states would say you
guys have the Timothy’s Law and you guys have well we
had the Affordable Care Act and the Mental Health
Parity and Addiction Act. But then there were all
these laws in New York State that happened to address
the opioid crisis. In 2014 there were a number of laws and then in 2016 we were
fighting really hard for an end to a prior auth and for bedded treatment as well as to get access right to medications and then for this LOCADTR
tool to be utilized. The sad thing is that even with all of these incredible
advances that have been made legislatively and regulation
there’s still so few people who really understand what parity is and it’s complex, isn’t it? – [Trisha] Oh, yeah. – So and we’ve talked about parity. I mean, literally it’s parity. It means that however you
treat medical surgical benefits you can treat or you can’t
treat the mental health and substance use benefits
any differently or any worse. – And I think the key
too is that folks think that just because they should, right? But I think your point
that it has to be on par and you said the same thing
T. that it has to be on par and that that’s where reading the plan, reading the contract is so important. – Right and it’s also why that
means you can be down here. We in New York have tried to
go up here with the rules. We exceed parity in
almost every single way or if anything what I think
is probably gonna become the case is we spend
more effort on looking at parity compliance. We’ve brought through our laws the world where it should have been
to comply with parity and that’s one of the things we’re gonna focus on moving forward. It is great to say you have
a law but if you aren’t able to ensure that people are following it it is a wonderful document
with words on a piece of paper and it has no meaning, it has no value so parity is one of the areas that we’re gonna focus on moving forward. So we’ve enacted all these
laws, we’ve gone through them and we’ve said frequently
as we go out and talk that if the laws aren’t followed they have no value, no meaning. One of the things we had tried
to do for a number of years is to create sort of that
backstop, that protector, the person or group of
people who make sure that these laws are followed. That people get access to mental health and addiction treatment
and we are government so acronyms are our lifeblood. So in 2018 the governor’s
budget contained money to create an ombudsman program and we couldn’t leave it there
so we gave it its own name called CHAMP and our champ is Stephanie and so what does CHAMP mean Stephanie? – Well again to your point. In 2018 we really
advocated strongly for this and we wanted to have this
independent ombudsman program and also to be working in collaboration with our friends over at OMH. I know that both you and Emil over at OMH are doing an incredible
job at that collaboration piece and so we contracted
out with an organization called the Community Service Society. We’re also working with
Legal Action Center which has been doing just
an incredible history of advocacy for our population as well as the New York State Council for Community Behavioral
Healthcare to run this program and I sort of oversee CHAMP. – So what is CHAMP? Here we go, here’s the program name. – So it’s the Community
Health access to Addiction and Mental Healthcare Project. To your point we love acronyms. CHAMP is under again CSS’
administrative helpline so it’s the third choice
when you call this number 888-614-5400. – [Rob] Right. – [Stephanie] There is
a wide range of options that you can access but
if you need specific help with substance use or mental healthcare you would hit the third
option and with insurance and we would be able to
connect you to someone who would be able to walk you through that process.
– And that email that’s listed goes to you? – [Stephanie] Yes, that
goes directly to me. I look at it regularly on a daily basis and so it is [email protected] I am the ombudsman project director. Some folks like to call me the
ombudswoman project director or just the ombuds it
really doesn’t matter. What does matter is that folks
know that help is available. – [Rob] So and this is
a flyer we’ve created– – Yeah, there was a one
pager that we’ve circulated. It’s up on our website,
OMH also has put it up on their website, any of the specialists. We call it the five legged
stool so we’ve got CSS, we’ve got the Legal Action Center, the Legal Aid Society as well
as Medicare Rights Center. They all have access to this one pager as well as the brochure and
now we have some additional CBOs community based organizations that also are disseminating
this information. – [Rob] And this is a
project we’re gonna continue in perpetuity hopefully. – [Stephanie] Absolutely. – [Rob] So why would I
call this phone number? What would be the reason that
I would call this number? – Yeah so you would call this number if you needed access, well first of all it’s an educational number too. Let’s say for example in all
of the amazing information that T. provided that you have no idea of how to navigate this whole
world, it’s very complicated. You can call the number and say hey this is my insurance plan,
I’m not sure if my loved one has access to this kind of care. Can you help me understand it? So it’s a way to know your rights but it’s also if there are
barriers that you’re finding in trying to access care call the 188, you remember Crazy Eddie? Remember the, I’m hoping that
people get this number like embedded in their brains 888-614-5400 but you could call that
number and say to the person on the phone listen they’re
telling me something, it doesn’t make any sense to me. Can you help me get around
some of what’s happening? Help me understand what
they’re saying to me. – So it might be two purposes
though or at least two but one could be I can’t find a place. – [Stephanie] Yes. – Or I found a place and they’re
saying no I can’t go there. – [Stephanie] That’s right. – And we try to help
them in either instance. Find the place and make sure they can get through the front door.
– That’s right. – Or that they’re being told that they’re gonna be
kicked out of the place. – So it’s an important
new tool that we’ve added. We believe that these
are the kinds of things that we would do to make sure
the laws that we’ve enacted are followed which gives
them their meaning. So we also love FAQs so we’ve added a few in to just try to help people understand. So can the insurer we are
actually at already did this ask for all patient
records every time and T.– – [Trisha] No, it has to be reasonable– – [Rob] They can’t? – [Trisha] No. – [Rob] Do they? Don’t answer. (Trisha laughs) – Not every time–
So– Just so everyone understands
what that means is and we’ve seen it which is why I made the smart comment that I made. They can’t say like I
mentioned in all 20 cases what we used as an example. I want your full chart sent
to me so I can do a review to see if the care was needed. They should have a bunch of
it already and it doesn’t mean that they couldn’t look at
every record on some level and request a full chart
may be here or there. Reasonable was the word you used. – [Trisha] Exactly. – So am I only allowed
14 days of treatment? I think I may have beat that
one up and I think the guys, yeah I didn’t create the PowerPoint slide but it’s not enough nos.
– I did that one (laughs). But one of the other important
points I hope you would take if your policy is covered
by New York State law you are entitled to
the care that you need. It could be four days,
it could be 29 days, it could be 14 days. There is no rule in New York
that says you’re only entitled, everybody’s only entitled to
14 days so if you hear that tell them Rob Kent said
you’re wrong ’cause you are. You get what you need
and you get what you need place by place so as T.
said the rules restart every program you move to,
it’s not one set of 14 days. So for instance you could
go to detox for a few days and you could be then
moved to a residential or inpatient program the
clock starts again okay. We can’t admit you because
you’re on suboxone. So I think you guys
put this in on purpose. So in the midst of an opioid epidemic where medications are clearly
the front line treatment for treating opioid use disorder
you can never get somebody to start working on themselves
until you can get them physically in a place where
they can actually think and work on themselves. So and in the midst of
this opioid epidemic we’ve heard it frequently well we’re an abstinence
based only program and that is not legal said the council for the state agency that
oversees those programs. Every one of our programs must make Medication Assisted Treatment available within their building
or with a relationship with another provider or organization. So it must be made
available and no provider should be saying to you,
you can’t come to me ’cause you’re on
buprenorphine or methadone or absolutely impermissible. And I say that and I mean
it and I can tell you I’ve gotten calls from families. My son is on buprenorphine, this program is saying they can’t take him because
he’s on buprenorphine. Interventions are one of
the things that occurs in our world so I do my
own form of intervention. It usually involves dollar
signs in the word fine. This is not permissible. We are losing in New York State best set of information about 3000 people a year to drug overdose. Many of them for opioid overdose. You cannot deny people access to Medication Assisted Treatment and expect those numbers to ever decline. So you’ve heard it here, you can find documents
all over our webpage, you can find new rules
that we’ve published. Every OASAS licensed program must make Medication Assisted Treatment available. Every one of them has to allow anyone who was already on
Medication Assisted Treatment to enter their program. If any of you hear the
opposite you should reach out to my staff and I and we’ll yet again do another intervention that is not permissible,
it is not the rule, it is not the law and it’s
not the right thing to do. So Stephanie maybe you
wanna take this one. Your child does not need
to be in a hospital. Have we heard that before? – We certainly have and the
question would really be so how are you determining this? What’s the tool that you’re using? If your child needs medication
are you able to give them the medication that they need? Just like with any other
chronic illness we wanna be able to have standards of care in which people are getting assessed in
the way that they need to. Also we have family
members who are desperate and saying well can you help me? If I can’t get my child into a hospital or if I can’t get this, can
you help with Continuing Care? Can you assist me with other resources? And so we wanna encourage folks to know that those connections need
to be made and that their kids do have access to medication
and that the tools that those who are doing
the assessments are– – And two pieces related to this. One is we worked out a sort of statement of policy from our agency and from the
state Department of Health which oversees all hospitals. And we made it abundantly clear
that any bed in any hospital can be used to detox somebody. That is the rule, it’s on
our web page you can find it. That is a document that was signed by me and one of my colleagues
at the Department of Health who oversees the part of
the Department of Health that regulates hospitals
so any bed could be used. Another thing we’re really
focused on what about MAT? Medication Assisted Treatment
and this year’s budget includes some provisions to
really enhance this effort. So many people in crisis
and have overdosed or clearly in need of addiction
help, in many instances in need of Medication Assisted Treatment go through emergency
rooms for far too often they were quote unquote
stabilized and allowed to leave. For those who don’t know if you overdose and you’re reversed by
Narcan, wonderful thing. You have induced that person
into immediate withdrawal, you’ve taken their high away
so if you let that person leave the emergency room without
some type of intervention they are in withdrawal, I
can tell you what they do ’cause we’ve seen it far too often. They will go find the
drugs they were using and start using again and the
worst part is that a person who has been reversed their tolerance has been thoroughly disrupted. So if they use at the same
level they’re tolerating at that same level, they are
even more likely to overdose and even that much more likely to die as a result.
– At a higher risk. So we want buprenorphine to be offered in emergency departments in
every emergency department in the state and I say that
with the comfort that that comes right from the governor. He’s told us that ought
to be the standard of care in every hospital, emergency
department in New York State and that is part of his
budget this year which we hope in a future conversation we can say it’s now the law in New York State. There aren’t many hospitals
that are already doing it. It ought to be the rule every place. So what is this ED or ER Survival Guide? – So when I was in my previous role as the executive director
we would have advocates from around the state who would call, I would have phone
calls from people saying I’m at the emergency room. They’re telling me that
my kid has to leave, they can’t do anything for them. And so you and I and some
advocates have a conversation and you and Mr. Sheppard from
DOH put together this letter. Now I can tell you that very
shortly after that letter was created I got a call from
a mother who was desperate. Her child was in the
ER, I was close enough to bring another advocate with me. We showed up, she was being
told no we can’t do anything. Your son has to be discharged. We actually used the letter
right there to say to and we advocated on behalf of this child. Here’s this letter that
OASAS and DOH put together. You’re covered, there’s a waiver and we were fortunate enough
to have a hospital person there who was willing to do this. – And you turned the staff ’cause I know of the situation. – [Stephanie] Yeah. – You turned the doctor and the nurse into advocates with you. – Absolutely. And we were able to keep–
– So you arm them within their own administration. – Absolutely and we were
able to keep him there in the hospital for a while
until we were then able to link him up to a treatment
facility that could take him. We knew that the concern
was that if he was let go because he had overdosed
not once, not twice but several times that he was
at high risk to your point because he had been reversed he would die. And this has happened on
any number of occasions so anyway we decided that for New York to collaborate with our
friends at Greater Monroe Recovery Community Organization, our friends at Recovery Buddy as well as some other advocates. We put together the survival
guide to hand out to parents and to family members so that
when they went to the hospital they had sort of a checklist. There was the attorney general
offices hotline number, there was OASAS’ pick up
number that was on there as well as the Combat Addiction linkage. So there are a number of
resources on that guide if folks are really interested
in getting access to that I would encourage them to contact Friends of Recovery New York and you can get that document.
– And it’s on their home page. Yes. – And if I met one of the things
that we didn’t mention yet which I think is really important is when you are in the
emergency department and you or your child, somebody you know has overdosed specific to the medication doctors don’t need any
additional federal authority to prescribe or to
administer buprenorphine. There’s actually an
exception in federal law which allows a doctor to
give a patient buprenorphine directly while they’re in the
hospital and they can do that once a day for three days. So that gives an opportunity
if you really work with the hospital to
stabilize the patient, that gives you a chance to
find a treatment program and also another question
I would absolutely ask is do you have any connection with a peer? – [Rob] Right. – We’ve heard great stories about certified recovery
peer advocates in New York who are having tremendous
impact with individuals who’ve been in the ERs who’ve
recently been reversed. – Right and for those who don’t understand T. is talking about buprenorphine so of course we talked about
stigma at the front end. So two of the medications
I mentioned to you, methadone and buprenorphine
they’re controlled substances. You can be prescribed them by
the way for pain in any doctor or prescribers practice anywhere in the United States of America
for pain with no limits, nothing other than
regular limits that apply to any medication. When you use them for addiction treatment for methadone it can only be
done by a prescriber in a state and federally regulated
methadone treatment program and it has to be stored in a safe that rivals that of Fort Knox. For buprenorphine the doctor or prescriber needs to be federally certified,
take a training course. Well now it’s doctors, nurse practitioners and physician’s assistants. They’re limited in the number
of people they can treat and they’re subject to pretty
stringent federal oversight so T’s point is really key. There is this exception
in an emergency situation where the doctor, nurse practitioner or PA don’t need to have gone
through that extra layer of federal oversight. So again as we talk about
stigma and the real life impact of stigma there is a
great example right there. So credentials we’ve
mentioned here and there but there are all these names out there so what’s a CRPA or a C-R-P-A? – So a CRPA is a Certified
Recovery Peer Advocate and this is a individual
who is credentialed by the New York Certification
Board which is an entity that we’ve delegated our authority to. And they are someone that can work to kind of meet people where they’re at. A lot of the things that we’ve
seen, we’ve mentioned EDs they’re really relevant place for peers but also out in the community
to go and speak to people and work on engaging them in treatment. Or maybe somebody has been in treatment and they kind of fell off a little bit so you can send a peer into the community, they can speak with that
individual try and reengage them. So it’s really somebody to try
and offer lived experiences and kind of share and help that person get through what they’re going through. – So they’re in recovery themselves or they have a family member so they’ve got lived experience
with addiction issues. – [Trisha] Exactly. – So what’s a Certified
Addiction Recovery Coach? – A CARC yeah it’s a
little bit different there. They’re certified through another process. They’re not CRPAs I think
is really important to know and there is a certification
process that they go through but I don’t believe that they
can be billed through Medicaid which the CRPAs can be.
– CRPAs can. And the CRPAs are connected I believe to OASAS licensed facility
which the CARCs are not. – [Rob] Right. – Yeah. – So CASACs, what are CASACs? – Sure so a CASAC is a
Credentialed Alcoholism and Substance Abuse Counselor. So we at OASAS we actually
regulate this credential, oversee it and grant the
credential to individuals. So these are counselors who
work at our programs typically and they actually worked
directly with patients in a clinical function to assist them on their road to recovery
when they’re in treatment. – Great and see they’re
all folks that are relevant to all the things, all the programs, everything we’ve been talking about. So (laughs) a note of caution. A free plane ride is not a good sign. So I’m just gonna give you an
example of stories we’ve heard about people out of state
treatment situations and we’re very much,
first off I have to say we believe in the programs
that we license and certify. And there is available
treatment in New York State every day and a good portion of it we pay for so we pay our providers to make treatment available for people who can’t pay
themselves so understand that. But then understand this. We get plenty of examples
where people will go to an out of state program for treatment, they use this out of network
benefit, they might get charged for a 30 day episode of
care, a couple of $100,000, they pay 20 to 30%. What we’ve heard from
the insurance companies ’cause they don’t like this is actually one where we’re on the same page. They like it just as little
as we do but so many times the family is calling to access
their insurance in the state where that program is
’cause out of the goodness of these people’s hearts,
they paid for them to fly down there the whole family beware. Those programs by and large don’t work and I don’t wanna impugn
any state’s programs although I really could I
would say the following. We have on our website a find
addiction treatment tool. We have an Ombuds, we have T, you have me. We have all these resources
now that we make available, we have a HOPEline, you can
find treatment in New York State any day in many parts of this state. We stand behind that
which we fund and license. I can’t tell you the
first thing good or bad about any other state’s
programs ’cause I don’t know. I can give you frequent examples
of where they didn’t work and I can give you the
offshoots of many of those ’cause we’ve dealt with these families. They come home, they did not get better, their family’s bankrupted, they borrowed against their house, they used up their retirement
to pay that 20, 30% copay. We will find them help in New York State because we are New York State
we take care of our own. God I wish we could have prevented them from leaving in the
first place and wasting a couple $100,000 in the in state. So please access all these resources, take advantage of the rights
that we’ve provided to you, the protections we’ve made available but you should absolutely
be able to find treatment. So if somebody offers
you a free plane ride be really careful about
where that’s gonna lead you. Oh, we just have to use this. So Sam Quinones who wrote Dreamland which if you haven’t read the book you ought to read the book. It’s about how we got where
we’re at as it relates to this opioid epidemic and
we saw him all speak recently at a big provider event in New York State and he’s made this comment. He made it there, he’s
made it and published it in so many places so
much of what we deal with and so much of what we hear
from people who are suffering from addiction, it’s an
isolating, lonely disease. And so much of what we’re experiencing with the opioid epidemic and
I would say almost every other human tragedy that we come
across is this lack of connection with each other and with community. And so he used the phrase you
know the antidote to heroin is not just naloxone it’s
also connection and community. And he used the example
by the way of his own life where when he was growing up
and he grew up in California suburban neighborhood, he talked about how his mom would ring the cow bell when it was time to come home for dinner ’cause he was outside
playing with his neighbors. He said, “I go back to
that neighborhood now ‘there’s not a soul on the street. “They’re all in their houses
playing their video games “and doing whatever.” He didn’t mean to castigate
but his point was well taken. So much of what we deal with and so much of what we’re dealing with with this opioid epidemic and
why we’re trying to do things like recovery centers
and clubhouses and piers is we’ve got to reconnect with people. All the things we’re doing
will make it easier for people when they want help to get
it but if we don’t deal with these deeper issues we’ll never get to where we need to get to which is eliminating the loss of any life. So (laughs) you put this in. I get in trouble for
this one it’s a takeoff on the Serenity Pray or part of it. We saw this, I posted it, I got yelled at for I was told I was sacrilegious but so much of what we’ve talked about is exactly what this
young lady’s board says. I am no longer accepting
the things I cannot change I’m changing the things I cannot accept. That sort of our motto at OASAS, it’s been the governor’s motto about how we deal with this epidemic. It’s been our commissioner’s
motto, it’s how we roll, it’s the only way we know at this point, it’s the only way we
believe we’ll ever get to where we need to get to. So all due respect and no
offense meant to anybody who would take it. So here are some of our
resources, there are plenty. You can find pretty much
everything we’ve talked about. If you go to oasas.ny.gov our main website it will lead you to all these places. This video will ultimately
be posted on our website so please all of these resources are there for you to use. Everything we’ve done there are all kinds of other videos we’ve created. There’s versions of us
that were significantly, we’ll at least in my own stead
slightly heavier than I am at this point but they’re
all intended to educate so please they’re yours. We work for you, take
advantage of them, use them and as importantly tell others, right? We post stuff on our social
media share our information. We make it all available. You pay for it, it’s
intended for you to use but we encourage you as
we’re trying to do this as a community share it with other folks. Great so here’s contact
information for council’s office, my office and T. Trisha monitors that multiple times in a day and the Ombuds email Stephanie
monitors so please use it. The 888 number is monitored
by our contracting parties. It’s there option three correct? – [Stephanie] Option three CSS. – So please take advantage of these and educate others tell them about this. So with that we’re done. I wanna thank you guys for
what you do and for being here to help guide us through this presentation and I wanna thank you. Please use these resources, help us get to where we need to get to and end this epidemic that
is the opioid epidemic. Thank you and have a great day. – [Dave] I’d like to thank our presenters for today’s program. I hope you will all find it useful while assisting clients
in need of services. Your feedback is important to us. It helps us to know if we are meeting your educational goals and expectations. Once you have viewed the
presentation in its entirety and completed the quiz,
please follow directions to access to survey monkey website and take a moment to
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