Inpatient Mental Health Coverage Rare For State Insurance Plans

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The state’s top insurers were more likely to approve claims for mental health services in 2015 than the year before, but rates of rejection for residential care remained high, a new state report shows.

About 6.4 percent of claims for mental health services were rejected by eight top managed care insurers – down from about 8 percent in 2014 – according to an analysis of the 2016 Consumer Report Card on Health Insurance Carriers in Connecticut.

At the same time, insurers continued to deny more than one in six requests for residential behavioral health care. And the percentage of managed care plan enrollees who received any inpatient services for mental health was low, with most companies providing such services for fewer than 0.3 percent of all enrollees.

The analysis is based on eight companies that reported the same categories of data in 2015 and 2016 to the state Insurance Department, which changed the reporting format across the two years. The plans are: Aetna Life Insurance, Anthem Health Plans, Cigna Health & Life, ConnectiCare, Connecticut General, HPHC Insurance Co., Oxford Health Insurance and UnitedHealth Care.

The report shows that two of the insurers, Aetna and Cigna, rejected a full one-third of claims for residential mental health care. Only in rare cases were such denials reversed after appeals.

The vast majority of plan members who received mental health care did so as outpatients or in hospital emergency rooms, the report shows. Of the more than 163,700 beneficiaries who received any mental health care in 2015, only about 4,100, or 2.5 percent, received inpatient services. More than 162,000 received emergency room or outpatient treatment.

Daniela Giordano, public policy director for the Connecticut chapter of NAMI (National Alliance on Mental Illness), said that while people with severe behavioral problems should “not have to fight” for needed inpatient care, the overall trend towards community-based treatment is a positive one.

Of concern, she said, is whether patients are being properly transitioned from inpatient treatment to community services.

“It’s the transition we’re always concerned about,” she said. “Is there actually a transition plan, or just a discharge plan? Are efforts being made to connect people with community providers?”

The 2015 report shows that only about 60 percent of enrollees in the eight health plans who were discharged as inpatients for mental illness in 2015 had an outpatient visit or partial hospitalization within seven days. One of the insurers, HPHC, reported that more than 90 percent of its members had such follow-ups.

The report shows that the eight companies denied an overall average of about 18 percent of claims for mental health and/or substance abuse treatment, with the highest rejection rates at Aetna (32 percent) and Oxford (17 percent), and the lowest at HPHC (3.3 percent) and Anthem (4.7 percent). For medical services, denial rates ranged from seven percent to 26 percent.

Across all claims, three insurers had higher overall denial rates last year than in 2014 – Anthem, Oxford and United — while the others had lower rates.

Results from a member satisfaction survey included in the report ranked Cigna and CT General the highest in ensuring that members who needed care right away received it “always” or “usually.” Anthem and ConnectiCare got the highest marks when members were asked how often, in the last 12 months, they got appointments with specialists as soon as they needed them.

Concerning health screenings, HPHC reported the largest percentage (close to 100 percent) of women ages 52 to 74 who received mammograms from 2013 to 2015, while Oxford Health reported the lowest percentage (about 70 percent). Fewer than 15 percent of all female adolescent enrollees in the eight plans received all three doses of the HPV vaccine by their 13th birthdays.

The two largest managed care companies—Anthem, with 989,284 members, and Aetna with 375,285—both grew from 2103 to 2015, according to the report. The third largest company, Cigna, saw a membership decline.


4 thoughts on “Inpatient Mental Health Coverage Rare For State Insurance Plans

  1. Why is it that value options never says no to a single behavioral health admission in the state of Connecticut . Because they manage the states Medicade dollars. The light is always green no matter how many admissions that person has had.

  2. NAMI again spouts the ridiculous in believing that outpatient care is sufficient for all. NAMI are pawns for insurance companies and they fail to acknowledge this reality. That poor ppl with Schzophrenia and mood disorders get their care in our prison system. Skewing real statistics these unfortunate ppl are forgotten and sadistically incarcerated, forced medicated amd released from court without a prayer. Shame on NAMI … AGAIN