LCL may help navigate managed care roadblocks

Issue September 2004

Q:In the last issue (August 2004), we published a question from a woman who was dismayed that her attorney husband's insurance would not cover inpatient alcohol-related treatment. That column addressed the issue of inpatient and "partial hospital" care. This month we deal with the second part of her question: "We were further dismayed (and angered) to find, despite Massachusetts 'mental health parity' law, that his insurance limits him to something like eight sessions. Does it make sense to you?"


A:Managed care's raison d'Ítre is to save money, reduce skyrocketing health insurance premiums (though it does not seem to have had this effect) and, in most cases, maximize profits. Cuts in services have been more dramatic in mental health/substance abuse than most medical services. Though the cost managers have been a bit kinder to outpatient treatment than to inpatient, they have nevertheless erected a number of gateways and obstacles to try to contain costs.

It is true that the Massachusetts Mental Health Parity Law of 2000 mandates that the limits of coverage for mental health conditions cannot differ from that for physical conditions. However, the law contains some very significant restrictions:

•  It only applies with full force to so-called "biologically-based" mental health conditions, including major mood and psychotic disorders as well as certain anxiety disorders.

•  For less severe mental health disorders, insurers must cover up to 24 sessions per year, and few if any exceed that "minimum maximum."

•  Alcohol and substance abuse disorders, though they would appear to fit within both the "biological" and "mental health" categories, are excluded from both. For these disorders, the mandate is only for $500 worth of services per year (which might come out to around eight sessions at managed-care-discounted rates). So if one is both alcoholic and depressed, for example, there may be significantly more coverage (via the depression diagnosis) than there would be for alcoholism alone.

•  If your employer is "self-insured," meaning that health claims are paid with the employer's own funds (i.e., in which the insurance company merely administers the process), the parity law does not apply at all, and the plan can impose whatever limits the employer desires.


Regardless of the supposed annual maximum, however, managed care plans need not cover these services beyond the point that they consider "medically necessary." When the patient sees an "in-network" provider (mandated by HMOs, and encouraged via financial incentives in PPO and POS plans), the managed care company will usually authorize an initial eight to 12 sessions. If further treatment is desired, the therapist must complete and submit (just before the authorized sessions run out) a detailed request form disclosing much more about the patient's problems and progress. Typically, a few more sessions will be authorized per request, followed by the need to submit more forms and client information.

Obviously, this system builds in incentives for the clinician and/or patient to lean toward a brief course of treatment. It is certainly not designed to minimize relapse potential, and tends to ignore the multiple medical, legal, commercial and family consequences of active addictive behavior.

Since LCL's staff is familiar with "how the game is played," we may be able, in various ways, to assist when any lawyer, judge or law student bumps up against these roadblocks to adequate coverage.


Questions quoted are either actual letters/emails or paraphrased and disguised concerns expressed by individuals seeking assistance from LCL. Questions for Lawyers Concerned for Lawyers may be mailed to LCL, 59 Temple Place, Suite 1106, Boston, MA 02111. LCL's licensed clinicians will respond in confidence.