On Sept. 24, 2019, Gina Moses received an unusual phone call from her teenage daughter. The girl was on vacation in Las Vegas and wanted her health insurance information.
When Moses asked why, everything tumbled out: The fight with her boyfriend, the suicide attempt and the trip to the emergency room. She called her mom from the hospital bed.
“She begged me to come get her,” Moses said. “She told me that she just wanted to come home.”
Moses lives in Albertville with her husband and two younger children. Within hours, she was on her way to Nevada.
“I stop and breathe and then pray for my daughter and for our family,” Moses wrote in a journal. “I pray for a safe trip to Vegas. I pray that I handle this in the right way to where it doesn’t affect the little ones.”
Moses and the teen spent the night in the same downtown Las Vegas hotel room where her daughter tried to take her life. When the boyfriend came back, the teen changed her mind about returning to Alabama.
“At that point, I realized just how delusional she was,” Moses said. “It was like she didn’t realize I had just flown all the way across the country to take her home.”
In Alabama, the daughter’s therapist said she would need residential treatment to learn how to subdue self-destructive thoughts. Under Moses’ insurance plan, the family’s out-of-pocket costs capped out at $875.
Then a problem emerged. Although the insurance plan covered residential mental health treatment, Blue Cross Blue Shield of Alabama wouldn’t approve payment for the types of private programs the girl’s therapist recommended.
Her issues mirror those of other insurance customers nationwide who struggle to get access to mental health benefits, in spite of two federal laws passed to make it easier to get coverage. Such challenges have persisted despite rising rates of suicide across the nation and in Alabama.
In Alabama, suicide is the second leading cause of death for people in their teens and early twenties, according to the Alabama Department of Public Health.
Alabama also has the nation’s smallest mental health workforce per capita, according to the United Health Foundation, and the least competitive insurance market. Blue Cross Blue Shield of Alabama covers nearly 3 million people, or 86 percent of the private insurance market in the state, according to the American Medical Association. That leaves Alabamians with few options for care and coverage of life-threatening mental illness.
“Do I think we would have had a second suicide attempt if we had been able to get residential treatment the first time around?” Moses asked. “No. She would have been there six months and she would have been over it.”
Guidelines and gatekeepers
Blue Cross Blue Shield of Alabama uses Kansas-based New Directions Behavioral Health to manage its mental health network and benefits.
New Directions acts as the gatekeeper for several Blue Cross plans, said Meiram Bendat, a California attorney involved in a lawsuit against the company. He said the company makes it
too difficult for customers to receive coverage for residential mental health treatment, even for patients with life-threatening conditions.
Susan Hering (a pseudonym used in the litigation) sued New Directions and Blue Cross Blue Shield of Florida after they refused to cover residential treatment for her anorexic 20-year-old daughter. At 5-feet tall, the young woman’s weight fluctuated between 60 and 70 pounds, more than 30 pounds underweight for her size, according to the complaint. Yet New Directions wouldn’t authorize residential treatment.
“The premise of the complaint is that New Directions is making coverage determinations regarding residential treatment that are not consistent with clinical guidelines,” Bendat said.
In her case, Moses said, New Directions never officially denied coverage, but wouldn’t approve it without additional referrals. Moses said they travelled to Children’s of Alabama in Birmingham to get another recommendation for the insurance company.
The doctor at Children’s agreed she needed residential care, Moses said, but would require the teen to wait days in the emergency room for a psychiatric bed if they wanted to keep her there until insurance came through.
If she needed another referral, the doctor suggested she seek one elsewhere.
Dr. Eric Plakun, the medical director of the Austen Riggs Center, a residential treatment center, said residential facilities can help provide long-term rehabilitation after patients get past the immediate crisis. Then outpatient therapy reinforces those lessons.
Those three levels of care also exist in medical treatment.
“If someone has a stroke, they are pretty ill, and they go to the ICU and an inpatient level of care until they are stable,” Plakun said. “The crisis needs to be stabilized and then it would be great to send them home to outpatient therapy. But we don’t send them home to outpatient if they can’t walk, talk or take care of themselves. We send them to a residential level of care until they recover most of those skills.”
Moses said her daughter recovered from the suicide attempt but remained erratic. Some mornings she seemed upbeat and ready for treatment. Other days she lashed out and told her mom she didn’t want to go.
“After she agreed to treatment, our biggest struggle was that she was like, let’s just hurry up and get there,” Moses said. “But my struggle was, I kept getting denied. Those days of apprehension, of her having her bag packed by the door, waiting.”
Moses tried everything, calling more than two dozen treatment facilities across the South and researching special “single case agreements” that would allow insurance coverage.
“I know that it’s a long shot, but at least it’s a shot,” Moses wrote in her journal. “If the single care agreement isn’t approved, we have to pay private pay rates. I know we can’t afford them, but I keep pushing forward just in case a miracle happens.”
Parity in practice?
Federal lawmakers enacted two sweeping laws in recent years to improve coverage of mental health.
Congress passed the Mental Health Parity Act in 1996 and strengthened it in 2008. Those bills prevented insurance companies from imposing lower limits on mental health coverage than medical and surgical benefits, but only applied to plans that already offered mental health coverage.
In 2010, Congress passed the Affordable Care Act, which in part required insurance companies to cover mental health and substance abuse treatment.
Under both laws, all insurance plans sold in Alabama must cover mental health treatment at the same level as other medical services.
Attorneys are testing those laws in the courtroom. A federal judge in California last year ordered United Healthcare’s behavioral health unit to overhaul its coverage of residential care
Joseph Spero, chief magistrate judge of the U.S. District Court for the Northern District of California, determined the company placed profits ahead of customers in need of mental health treatment.
The same attorneys who sued United Behavioral Health have now come after New Directions Behavioral Health. They argue company guidelines put treatment out of reach for patients denied insurance coverage for mental health treatment.
The Health Care Cost Institute, a data research organization affiliated with several major insurance companies, found that out-of-pocket costs for mental health care increased faster than other medical treatment from 2012 to 2017.
“We’ve seen families that have sold their homes,” said Caroline Reynolds, an attorney involved it the New Directions case. “We’ve had families that are liquidating their 401(K)s. They’re doing all sorts of things just to keep their kid in care. And we’ve also seen families where they can’t do it and the person has to forego care, sometimes with deadly consequences.”
The high cost of mental health
In Alabama, Tallison Rausch spent more than $50,000 out-of-pocket on residential substance use treatment not covered by Blue Cross Blue Shield of Alabama. That’s according to a complaint filed with the Alabama Department of Insurance. Her doctors recommended she follow up with one month of intensive outpatient treatment.
New Directions denied it as medically unnecessary because Rausch hadn’t used in more than four months. That left her with a bill of $1,000 on top of her $1,000 co-pay.
Rausch, who has worked in the medical and insurance fields, used her knowledge of the system to fight the denial. Insurance ultimately paid the bill, she said.
“I know that they’re going to deny every so often just on the probability that the patient wouldn’t know what to do,” she said. “It was a pain in the ass to write that appeal. I just don’t know what other people without my background would do.”
New Directions’ standards for residential treatment require patients to be very ill, either actively in danger or deteriorating fast. They also demand proof a program works better than a lower-cost alternative such as outpatient therapy.
“New Directions partners with health plans and abides by the Mental Health Parity and Addiction Equity Act,” said McKenzie Cordell, a spokesman for the company. “To protect our members’ privacy, we are not able to share any information about specific cases.”
Paul Crits-Christoph, a professor of psychiatry at the University of Pennsylvania, said there’s little evidence residential treatment works better than outpatient. Requiring insurance companies to cover unproven treatments can drive up health care costs for everyone, Crits-Christoph said.
“To be honest, the insurance companies are on reasonable grounds unless there’s a clear benefit,” he said of denying payment for residential programs.
Attorneys for Blue Cross Blue Shield of Florida and New Directions made a similar argument.
“Simply put, there is no single source for the ‘generally accepted standard,’” attorneys wrote, arguing there’s no scientific consensus to support residential treatment for mental illness.
Coverage at all costs
New Directions approved outpatient treatment for Moses’ daughter in Georgia, but the program focused on substance abuse. Although insurance paid for treatment, the family paid for housing. The daughter received little of the behavior treatment recommended by her therapist.
Moses and her ex-husband switched their daughter to his insurance, starting in January. Before then, Moses’ fears came true. The teenager overdosed on medication in December and the family rushed her to a nearby hospital.
The teen’s second suicide attempt sent her to the psychiatric unit at Children’s Hospital of Alabama right before Christmas. During the first 32 hours, her vital signs plummeted. Staff pinched her toes and shone lights in her eyes as she dipped in and out of unconsciousness.
Medical staff got her to the other side of the crisis and started talking about discharge. Moses did not want a repeat of the fall, or another suicide attempt. She asked the hospital to hold her daughter until Jan. 1, when the new policy kicked in and she would be eligible for residential treatment. That meant keeping her in a locked ward at Children’s over Christmas. On Christmas Day they had only four hours together and couldn’t exchange presents.
“Everything is set up for safety for the patients and staff,” Moses said. “Four block walls, steel doors with locks and windows, rubber beds, saloon doors for the bathrooms.”
In January, she transferred to a residential facility in Tennessee for one month. From there she traveled to California for follow-up treatment, which was covered under the new insurance.
In June, the daughter came home.
“We don’t know when it’s going to happen, but it’s going to happen,” Moses said. “There’s going to be a trigger, and I don’t know how we’re going to handle it, but we’re going to handle it.”
Concerns about insurance linger. Her ex changed jobs during the summer, and Moses’ husband couldn’t add her to his new plan. The leaves the daughter temporarily uninsured.
But things could change in Alabama. Bendat said New Directions uses a standard set of guidelines in all states where it operates. If the lawsuit in Florida forces a change, Alabama coverage could be affected.
“It’s hard to believe that New Directions will be able to maintain the same clinical standards in states where they haven’t been sued,” Bendat said. “What we’re challenging are the guidelines they use in all the states.”
If the teen needs medical or mental health care, Moses will add her back to her Blue Cross plan. If needed, the family will dig deep into its savings to pay for the care she needs.
“Of course, that’s a big concern of ours, insurance coverage,” Moses said. “Whenever we look at her treatment and our options, there’s no limit to what we would do to save our child. Just like if she had leukemia. We would have mortgaged the house. We’d do whatever we could. There’s no other option.”