As the opioid epidemic continues to get worse, some are blaming the health insurance industry for not making it possible for people with pain pill / heroin addictions to get the proper treatment.
The New York Health Plan Association said it is a complex issue that is controlled in large part by state regulations and requirements.
"What is appropriate and deemed medically necessary does not always match up with what people want," said Leslie Moran, senior vice president for the association.
Two of the biggest concerns raised by critics are the inability to get payment for in-patient treatment and special medicines to help break opioid addictions.
The New York State Office of Alcoholism and Substance Abuse Services provides the following link to find beds and facilities for treatment.
7 Eyewitness News also reached out to Blue Cross Blue Shield of WNY to get clarification on treatment options for its members.
-The use of medicines to help break addiction to opioids (Suboxone)?
1. BlueCross BlueShield of Western New York supports the use of all medically assisted treatments for our members including suboxone, vivitrol and methadone.
2. No pre-authorization is required under our prescription drug benefit for our members.
-The use of Naloxone?
1. BlueCross BlueShield supports the use of naloxone to prevent overdoses.
-The use of in-patient treatment for opioid addicts?
1. Inpatient detoxification is considered a medical benefit and does not require pre-authorization.
2. Inpatient rehabilitation and sub-acute inpatient residential care (Residential treatment) are unlimited, medically necessary benefits.
3. Pre-authorization for our members (and all New York residents) is subject to OASAS LOCADTR 3.0 approval. The LOCADTR tool determines the approved level of care.
4. Non-clinicians (family, courts, advocates, etc) frequently do not understand what the different levels of care entail or that the OASAS LOCADTR tool determines the assignment. This creates confusion in the community.
5. BlueCross BlueShield of Western New York has been a leader in the State over the last 5 years with moving Health Plan practices away from focusing on cost containment to providing recovery oriented services centered on patient need and requirements. (We were an early adopter of Horizon Village residential model, launched and sponsored PainKillers Kill, our health plan was an early adopter of OASAS LOCADTR tool, and the lack of preauth on medically assisted treatment.
7. There is a shortage of certified service providers in NYS as well as nationally. The opioid problem will not be something we can end with treatment alone.
6. This is a national epidemic that has taken two decades to reach a crisis stage. There is no easy fix. It is a system wide problem that must be addressed through physician education, community engagement and member awareness, along with a significant expansion of the service network, integration of behavioral health and physical health care as well as support by law enforcement and regulatory efforts.
The NYS Senate Task Force on Heroin and Opioid Addiction's 2016 report, we are noted as the ONLY health plan that participated in any of the 9 hearings that took place across New York State, hosted by Senator Ortt last May. We currently serve on the Erie County opioid Task Force with Dr. Gail Burstein and many other key stakeholders.
Julie R. Snyder
Vice President, Corporate Relations
BlueCross BlueShield of WNY
257 West Genesee Street | Buffalo, NY 14202