A set of new laws that went into effect at the start of 2017 can make it easier for people with heroin and opioid addictions to get help…and for treatment providers to help them. One change for treatment involves whether insurance will cover it. Syracuse Behavioral Healthcare CEO Jeremy Klemanski will have one less hurdle when trying to provide treatment to an addict…and having to prove they need it.
“The provider of the services, an organization like ours for example, no longer has to spend hours or in some cases days trying to prove that before we’re able to provide care to that person… and get reimbursed for it.”
In fact, there’s a new tool that can be used to determine need and clear up any coverage questions
“We can very quickly identify what level of care does a person need and communicate that with the insurance provider. Any then if there is any disagreement about that, well, we have the tools to follow to help guide our conversation. And then it’s not a matter of opinions between clinicians and two different entities; it’s really a matter of fact.”
Insurers are also required to cover the first 14 days of treatment for someone needing immediate care. Klemanski says that first contact can help steer someone away from looking for the next fix.
“If a person comes in, going through very destabilizing, painful withdrawal process, our ability to stabilize them medically in the first one-to-three days will often determine whether or not they feel safe enough physically to stay and engage in treatment. Or the distress and discomfort is creating so much strain on their body, so much fear because of lack of control of their own body that those folks oftentimes would walk out of a facility and go find an illicit substance on the street to stop that withdrawal so they didn’t have that fear anymore. Well now, we’ll be able in any instance to provide that medication.”
Insurers cannot require prior authorization for drugs such as Vivitrol to ease addiction or Naloxone to reverse overdoses. Another area of change will be expanded wraparound services. Klemanski says for many people trying to recover, short term treatment is not enough.
“The science today tells us that substance abuse disorders are progressive and they are chronic, which means just providing acute or short-term intervention or treatment, and then sending somebody on their merry way, really doesn’t set them up for long-term success.”
OVERVIEW OF CHANGES TO INSURANCE LAWS FOR 2017
- End Prior Insurance Authorization to Allow for Immediate Access to Inpatient Treatment as Long as Such Treatment is Needed: Insurers must cover necessary inpatient services for the treatment of substance use disorders for as long as an individual needs them. In addition, the legislation establishes that utilization review by insurers can begin only after the first 14 days of treatment, ensuring that every patient receives at least two weeks of uninterrupted care before the insurance company becomes involved.
- End Prior Insurance Authorization to Allow for Greater Access to Drug Treatment Medications: Insurers cannot require prior approval for emergency supplies of drug treatment medications. Similar provisions that also apply to managed care providers treating Medicaid recipients who seek access to buprenorphine and injectable naltrexone took effect in June.
- Require All Insurance Companies Use Objective State-Approved Criteria to Determine the Level of Care for Individuals Suffering from Substance Abuse: All insurers operating in New York State must use objective, state-approved criteria when making coverage determinations for all substance use disorder treatment in order to make sure individuals get the treatment they need.
- Mandate Insurance Coverage for Opioid Overdose-Reversal Medication: Insurance companies must cover the costs of naloxone when prescribed to a person who is addicted to opioids and to his/her family member/s on the same insurance plan.
State programs are adding to counseling, legal and employment support services. Doctors will also have to comply with new state limits, reducing the number of opioid painkillers they can prescribe from 30-days’ supply down to seven. New York had the highest spike in death rates from heroin and opiates in the nation – jumping 135 percent from 2014 to 2015.
