This story isn’t new. In fact, it’s the same story for many people and families all over the country. It looks like this: Rehab insurance policies often refuse to cover inpatient care as a first option, instead preferring to direct clients to outpatient services that are inadequate for their needs.
Take the story of a mother in Staten Island. She looked to her private insurance provider to cover her son’s treatment for a progressive heroin addiction and was constantly denied help. The paperwork from the insurance company began to accumulate while her son continued to get high. Folders containing denials from her provider, Emblem Health, turned down her 24-year-old son, Adam, time and time again. The company turned them both down, keeping them from getting the kind of care experts say opioid addicts need to get better. Instead of inpatient care, the insurance company offered only outpatient services, which weren’t enough for her son’s needs.
Months went by while Adam got worse. He stole, got high, stole more, got kicked out his house and eventually was arrested for heroin possession.
“He came home so stoned he couldn’t even stand — I was terrified,” said Vicky, a city teacher, recalling the first time she learned her son was using heroin. “I called 911 and they took him into the emergency room, and that’s when I found out he was doing heroin. It was devastating.”
Rehab Insurance Policies Want Clients to “Fail First”
Insurance companies are allowed to refuse coverage for inpatient care. Rehab insurance policies often use a “fail-first” model of recovery.
Explains Jacqueline Fiore, executive director of Staten Island YMCA Counseling Service, which provides outpatient services to addicts: “It’s left up to the provider and the client to prove the need for this level of treatment. Sometimes it’s a fail-first model, where you have to fail outpatient visits before you can be approved for inpatient,” Ms. Fiore said. “For people with this type of addiction, that could very well mean overdose or death. A failure could mean death, and that’s the part we’re constantly advocating for change with.”
Unfortunately, the reason for denial usually comes down to cost. Luke Nasta, executive director of Camelot Counseling Service, an inpatient facility on Staten Island, says private insurance doesn’t want to cover expenses that come with long-term treatment.
“Insurance companies are an industry. It’s a business,” he explained. “They don’t want to spend money if they don’t have to, especially on a problem that’s so widespread. They’d rather shovel more coin into the vault.”
What Is the Fail-First Approach to Treatment?
Fail first, also known as step therapy, is a form of addiction treatment coverage that requires the patient to try one or more alternative treatment options before accessing the treatment originally recommended by their doctor. This is something many people would consider controversial for diseases such as cancer, but the stigma around substance abuse leads to some individuals simply accepting such requirements.
Parity regulations aim to remove some of the discriminatory practices surrounding health care for people living with substance abuse. Under parity regulations, any limitations or barriers to rehab access are compared to the limitations or requirements faced by patients with other medical or surgical requirements. Insurers are required to provide equal access to care, regardless of the condition.
Failing First Puts Substance Abuse Victims at Risk
The fail-first approach to care puts patients at risk. Adam did well when he had access to inpatient treatment. However, when his insurance company stopped paying, he relapsed almost immediately. Vicky has removed her son from the insurance plan and put him on Medicaid so he has access to better treatment options.
Experts say people engaging in substance abuse are more likely to recover if they start in residential treatment and work down to less intensive treatments later in recovery. The 24-hour care they receive in a supervised environment can help with the physical and mental aspects of rehab. Polls conducted by the PAN Foundation have found that the fail-first approach can delay a patient from accessing their originally prescribed treatments by as much as 11 weeks.
Around 21% of patients who were required to go through fail-first treatments had to go to the emergency room as a result, with 20% being admitted to hospital. When patients have access to a continuum of comprehensive care, they get the support they need more quickly. This results in a higher likelihood of successful treatment.
Support Is Available for Substance Abuse Patients
Fortunately, it’s possible to access inpatient care for substance abuse disorder. Health insurance policies might not always cover 100% of the cost, but sometimes they do. When you contact a treatment center, the staff can verify your coverage and advise you whether other financial support options are available. Many rehab centers offer a sliding fee scale to help patients access the care they need even if they’re on a low income.
Get in Touch
If someone you care for is struggling with substance abuse or you’re looking for help for yourself, contact FHE Health today for information about our rehab facilities and fee structure.
