June 2024

Working With Employers of

Self-Funded Plans

If you work for a large company or a union, chances are that your health plan may be self-funded.  What this means is that your employer pays a company like Cigna or Aetna to act as a Third Party Administrator (TPA), making all the routine decisions, while they (the employer) pays the TPA for the actual claims.   MHAIP has recently started working more diligently with employers, and we have found that in many cases, they play a significant role in helping families get coverage.  This is especially so when you are not being treated fairly, such as when the plan does not acknowledge or pay claims that have already been authorized, or fails to timely respond to claims or appeals, or issues blanket denials that are not mentioned in the plan manual, or a variety of other roadblocks that our families often encounter in their quest for coverage or reimbursement.   Health plans are typically supposed to process and pay or deny claims in 30-45 days.  Generally they are required to respond to grievances and appeals in that same amount of time.  If they do not, we encourage you to pick up the phone and try to find out what is going on.  Take notes and request a reference number.  If that does not work, file an appeal or a grievance (an appeal is a response to an adverse determination, while a grievance can sometimes be used to kick off the appeals process when a denial is not forthcoming).  In this business, anything but a yes and a check is a no. 

When the plan denies for either medical necessity or because something is not covered, they are required to tell you why in a denial letter.  For non-coverage issues, they are supposed to quote the provision in the plan manual that excludes or explains why something is not covered.  When services are denied because they are not medically necessary, the plan is supposed to give you a specific reason as to why you did not meet their criteria, and provide you with a copy of the criteria upon request.  If they reviewed your medical records or you were denied during the utilization and review process, they are also supposed to allow you to review their clinical notes, again upon request.  Request these documents and put the request in writing if the plan is not forthcoming. 

If the plan does not follow these steps, or if they fail to respond to claims or other complaints, reach out to the employer.  Tell them the problems you are having and let them know that the health benefits in the plan are not being administered properly by the insurance company. Start with your HR contact and if they are unsure or unwilling, make sure that the issue gets elevated to corporate HR. It sometimes helps to flag this as a “compliance” issue, with large employers. Occasionally you may be referred to a person who functions as a liaison between the health plan and the employer.  If the concern is about claims processing, ask the employer to find you a direct contact within the health plan who can track the claims along with you.  

Some employers retain decision-making authority over the health plan, while others do not. Some employers have a separate claims committee which gives an extra level of appeal consideration.  Regardless of the contractual arrangement, however, the employer has the final say by finding a new TPA at the next open enrollment period if they are dissatisfied with how their employees are treated.

At MHAIP, we reach out to the employer and give them an opportunity to investigate and respond before we file a complaint with the Employee Benefits Security Administration (EBSA) of the US Department of Labor.   See the case below “MHAIP Obtains Seven Additional Weeks….”.  The EBSA has the authority to investigate employers when they or their TPA are not following the law.   If you are handling your own appeal or complaint, we encourage you to do the same.  The DOL has identified mental health parity as a priority issue within their department, and the time is ripe to involve them, especially when other avenues have not been successful. 

Highlights From Recent Appeal Wins

MHAIP Obtains 7 Additional Weeks of RTC by Working With Employer

MHAIP does not hesitate to inform employers about the failings of their plan administrators, which sometimes leads to favorable outcomes for the employees. MHAIP was able to secure an additional seven weeks of residential treatment for a young person diagnosed with autism spectrum disorder, unspecified depressive disorder, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, obsessive compulsive disorder and emerging gender dysphoria.  The patient had attended a wilderness program, and was recommended to attend a continued structured program, on discharge. The benefit plan expressly committed to in-network rates when no in-network care could be found, and the employee had clear notes (which we always recommend) regarding the non-availability of network providers. MHAIP was able to obtain payment at the highest in-network rate, both for the initial two week authorized period, and the additional seven weeks to the end of the plan year. This was one of the worst cases of claims maladministration we have seen, but the employer stepped up to the plate to help MHAIP gain the clinical criteria which should have been supplied with the denial and to get the appeal to the correct place, both of which are major examples of ERISA non-compliance. MHAIP’s appeal for coverage beyond the initial period emphasized the significant impact of the co-morbid diagnoses, particularly the ASD, on the response to treatment. It was clear that the employer felt significant responsibility (as they should) for the fact that UMR was making continued misstatements about whether or not a peer review had been scheduled in a timely manner.  The employer was pro-active in ensuring not only that the denial was fairly addressed, but that the claims were then reprocessed correctly. 

7 Weeks of Inpatient Hospitalization Level Care Secured

We won a significant victory in the external appeal overturn of a 12-year old’s stay at the psychiatric inpatient level of care at Huntsman Mental Health Institute. Inpatient psychiatric level of care is a higher level than residential treatment level of care, and difficult to prove the need when denied by health insurance companies. Aetna denied his care after 3 weeks, but his medical team wanted him to remain for another 7 weeks. The boy had multiple mental health diagnoses and a well-documented history of past treatments and refusals by facilities to accept him due to his behaviors. We showed his continued need for inpatient level of care both behaviorally and due to his medications and won coverage for all of his dates from admission through discharge - a coverage amount of $77,500. This victory was very sweet for the boy’s mother, who is a medical professional and knew he needed the treatment.

3 Month Stay at In-Network Rate Covered for Young Adult with ASD

MHAIP won an important victory in getting full coverage for a young adult with autism at Pacific Quest Residential Treatment Program in Hawaii. Young adults (over 18) are typically denied coverage for autism-related therapy, although the medical literature does not clearly show that people “outgrow” or “can’t make further progress” with therapy as they age. This young man needed to complete Pacific Quest’s entire three-month program, but he was denied after 2 weeks. We showed his slow but steady progress in the program and Blue Shield of California reversed its denial and covered the entire three-month program at in-network rates.

External Review Overturn Compels Coverage of 2 Months of RTC

MHAIP advocated on behalf of the family of an adolescent with the complex set of diagnoses of trauma disorder, depression, anxiety and substance use disorder. The family has coverage through BlueCross BlueShield FEP (Federal Employee Plan) for employees of the Federal Government. Residential level care was denied upon admission as not medically necessary for this young woman who had 3 previous hospitalizations and had failed in lower levels of care multiple times. MHAIP filed and lost the internal appeal with FEP. We then filed an external appeal with OPM (Office of Personnel Management), which is the process for these types of plans. The external reviewing agency agreed with us that residential care was, in fact, medically necessary for the member. BCBS FEP has 30 days to prove compliance of the overturn order, ie reimburse the family, with OPM.

30 Day Stay Overturned for Young Adult with Eating Disorders

We won a 30 day stay in a short term RTC for a young adult from CA with eating disorders, ASD, anxiety and depression.  The young woman had lost over 20 pounds in a very short time-period. She had been seen by a Kaiser therapist at the time who told her that she would need to be seen by additional psychiatrists before they could approve treatment outside of Kaiser. In the meantime, her condition worsened and her parents urgently enrolled her in an eating disorder specialty program in Arizona. The family appealed, Kaiser denied because she did not keep her appointment with Kaiser's psychiatrists (due to being in residential treatment), and we assisted the family with their complaint with the CA Department of Managed Health Care. Initially, when DMHC brought the case to their attention, Kaiser said they would pay for the whole stay. Later, they reimbursed the parents but only for the initial enrollment fee. When we brought this to the DMHC's attention, they ordered Kaiser to pay the entire bill, which was over $50,000.

External Review Yields Partial Coverage of RTC at the In-Network Rate

We got part of a residential stay for a 17-year-old girl recently diagnosed with autism and unsafe behaviors covered in an external appeal overturn. Thanks to the girl’s mother’s hard work trying to find in-network care, not finding any, and careful note-taking of her conversations with facilities and Anthem Blue Cross Blue Shield, we were able to make a compelling argument that all of the girl’s care should be at the in-network rate, even though the facility was out-of-network. Anthem BCBS acknowledged it “improperly managed" her network status and approved in-network rate status for 9 weeks.

Work with Employer Results in Coverage for Adolescent with ASD

Based on our advocacy, CollectiveHealth agreed to pay for residential treatment for a 14-year-old boy with autism. MHAIP worked with the boy’s father to prepare all the material advocating for insurance coverage, which he presented to the executives at his tech company. Companies that have self-funded insurance policies will sometimes engage directly with their employees and consider overturning denials and will pay for mental health treatment.

Authorization for 7 Weeks of RTC Ordered by External Review

MHAIP was able to recover an additional seven weeks of residential treatment for a 20 year old young woman who attended a comprehensive treatment program in Texas.  The patient was diagnosed with anxiety disorder, attention deficit hyperactivity disorder, borderline personality disorder, and post traumatic stress disorder. The employer plan administrator (Anthem) initially approved treatment for a ten week period. However, Anthem then withdrew authorization for additional coverage, stating that they no longer considered that she was a danger to herself or others, or that she was having serious problems functioning, or that her condition was likely to further improve with the care or get worse without it. This went directly against the medical records which showed that her condition did indeed improve, such that she was eventually able to step down to a transition placement. Significantly, the withdrawal of treatment authorization came whilst in the middle of a course of treatment known as EMDR - Eye Movement Desensitization and Reprocessing. This is a psychotherapy treatment that is designed to alleviate the distress associated with traumatic memories.  This treatment is delivered in stages, and requires a period of adjustment immediately after each session.  However the health plan’s MD upheld the denial. The reviewer’s letter failed to address the EMDR, the history of suicide attempts, or any of the other individual circumstances of the treatment plan. MHAIP submitted a request for External Review outside of the Plan. The external reviewer agreed that the patient's admission, comprehensive evaluation and entire mental health residential treatment and services could not have been safely or effectively provided at a lower level of care. The reviewer noted the functional impairment, recognized the “emotional/psychiatric comorbidity with active symptoms” and failure to respond to treatment at a lower level of care previously. “Not until the completion of intensive EMDR therapy and other evidence based treatments, had the patient made progress, demonstrated fair and improved insight, and achieved a level of emotional stability and symptom relief that she could benefit from the continuing treatment and discharge to a less structured and less intense treatment setting”.

This decision is noteworthy because it supports the idea that it is unreasonable for a specified treatment modality to be interrupted, prior to its completion, to the detriment of the patient. Providers should note that intensive individualized treatments should always be cited on appeal, and withdrawal of authorization during the course of the treatment could potentially fall foul of Mental Health Parity law.

Parent of CA Teen told RTC Not An Option, Case Overturned in Medical Review

A 16 year old CA teen with major depression, ADHD and anxiety was denied RTC treatment. She had been refusing to attend school for several months, had multiple episodes of running from home, was smoking marijuana daily, and was often unable to get out of bed due to depression, and anxiety episodes. After being picked up by police and brought to the ER, her mother requested a higher level of care. She requested RTC, but was told that this was not an option. Instead, her daughter was offered a 10 day PHP program, which she left after attending only a few days. The mom was told by Kaiser that they could offer weekly outpatient therapy, but only for a few months. The mom then called Kaiser member services and requested a single case agreement because Kaiser did not offer her an appropriate in-network program. She was told that Kaiser does not offer single case agreements and that the only option was to file a grievance. We helped her file an expedited complaint with Kaiser. When that was denied, we assisted the mom with a complaint with The CA Department of Managed Health Care. DMHC sent the case to external review, and services were found to be medically necessary. She is currently at an RTC in southern CA. 

"When I felt exhausted and hopeless, a friend told me that I needed to call Mental Health & Autism Insurance Project and I had no idea what she was referring me to, but she said that you would help. That was an understatement. You took the time to listen to my daughter's entire story, and felt that we had a decent case. We were on a time crunch, but you walked me through every step and took over for me where you could. After Kaiser denied us twice, we quickly filled out the paperwork for the Department of Managed Healthcare. I appreciated you checking in with me during the wait, and handling all the paperwork and communication in between. It's such an emotional time when our children are struggling and in residential, so to have the weight of advocating for insurance rights off of my plate was huge. I figured we had a 50/50 chance, and tried not to get my hopes up. When we received the verdict in our favor, I cried such happy tears! I couldn't believe it. I owe it all to your expertise and dedication. I am so grateful for you and I wish more parents in my position knew about the small superhero organization that is MHAIP!"

Because of the Mental Health Parity and Addiction Equity Act (MHPAEA) and also the CA Mental Health Parity Act, most health plans cannot offer time limited programs (duration is based on need). If they tell you that they don't offer residential treatment or they don't offer single case agreements when the network is inadequate, they are likely violating the law. We encourage families to push back against these types of categorical denials. 

Highlights of Pre-Authorization/UR Services

  • Sara, a young adult with Major Depressive Disorder, Autism, and Generalized Anxiety Disorder from NJ, received 35 days of coverage from Horizon BCBS at a residential treatment program in Vermont.

  • Rebecca, an 18-year-old from CA with Generalized Anxiety Disorder, Major Depressive Disorder, and PTSD received 42 days of coverage from Anthem at a residential treatment center in New Hampshire. 

  • William, a 17-year-old from MD with ASD level 1, received 44 days of coverage from Care First BCBS at a residential treatment center in Utah.  William previously had his entire stay at a treatment center in Utah covered by insurance.  

  • Gabriella, a 14-year-old from NJ, with Generalized Anxiety Disorder, Social Anxiety Disorder, Major Depressive D/O and ADHD has had 49 days of her stay thus far covered by UMR at a residential treatment facility in New Hampshire.

  • Caden, a 14-year-old from CA with Autism Spectrum Disorder, Mild, Attention-Deficit/Hyperactivity Disorder, and a Specific Learning Disorder has had 68 days of his stay at a residential treatment facility in Utah authorized by insurance.

Thank You to Everyone Who Generously Donated to MHAIP in 2023!

Jennifer Barnard

Victori Ben Yaacov

Helen Bernett

Beth Boullianne

Eugene Chow

Beth Cohen

Linda P Drucker Charitable Gift Fund

Jeanne Dyess

Escher Fund for Autism

Fenexia Foundation

Bette-Ann and Norbert Fessel

Karen Fessel and Jeffrey Kirschenbaum

Rachel Force

Susannah Gardiner

Ed & Natalie Henrich Donor Advised Fund

Julie Kim

Debra Kirschenbaum

Amy Koster Green

Flora Kupferman

Charu Kush and Amit Kumar

Michelle Kwan

Terry Lowe

Anthony Manzanetti

Miley Family Charitable Account

Carol Morris

Jess Nerren

Peggy Orlin

Caren Orum

Matt Panuwat

John Park

Tammy Pedersen

Thomas Phillips

Jurgen Reich

Sarah C Jones

Terry Schmidt Farrell

Hunter & Marcy Coen Smith Family Fund

Andrew and Kelly Steggles Family Fund

Christa Stevens

Diane Tackaberry

Ben Tucker

Weinstock Coln Family Fund

Mathew White

Jorge and Corie Wong

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General Fund supplements our sliding scale program, pays for educational seminars and workshops for families and professionals, helps with policy work and allows us to provide free advice to families needing help with insurance.

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Donate to the Feda Fund

We will need your continued financial support to be able to keep this wonderful program, which allows us to provide assistance to financially struggling families and keeps Feda and Mu’s memories alive in our hearts.  Thank you for your active support.

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Helping families, providers and facilities obtain medically necessary mental health and autism treatments through health insurance.
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