When Rehab Might Help An Addict — But Insurance Won't Cover It : Shots - Health News Federal law requires insurance firms to cover treatment for addiction as they do treatment for other diseases. But some families say many drug users aren't getting the inpatient care they need.
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When Rehab Might Help An Addict — But Insurance Won't Cover It

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When Rehab Might Help An Addict — But Insurance Won't Cover It

When Rehab Might Help An Addict — But Insurance Won't Cover It

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RACHEL MARTIN, HOST:

Deaths from heroin-related overdoses are soaring. Opiate addiction now touches every group - white, black, Hispanic, rural, suburban and urban. But those seeking treatment may find their health insurance plan comes up short. Ben Allen from member station WITF reports.

BEN ALLEN, BYLINE: Growing up in the Philadelphia suburb of Warrington, Anthony Fiore hit all the check boxes for a typical American guy - go to the gym, play video games and watch football - in his case, the Eagles. His mom, Valerie Fiore, was proud of him.

VALERIE FIORE: Anthony was very intelligent. He breezed through his high school, Central Bucks South. He never studied. He aced his SATs. He got right into Penn State main campus.

ALLEN: Before he could get to Penn State, the powerful painkiller OxyContin grabbed a hold of him. Soon after, he moved on to heroin. In May 2011, Anthony tried a 21-day rehab in Florida. About a year later, he visited another facility, but only for 11 days. By the third attempt at inpatient rehab, Anthony said he really wanted to get help and would stick it out.

FIORE: And that was a 21-day treatment, and that's when I had Premera Blue Cross. And that's the one that I begged for them to keep him. And that gentleman said to me, your insurance will not cover any more.

ALLEN: Anthony left that rehab in November, 2013. Six months later, he was dead of a heroin overdose. In a statement, Premera Blue Cross said its medical policies are informed by national experts. Every case is different, but for the most severe ones, professionals recommend a sober inpatient stay of at least 30 days, plus intensive outpatient treatment that can include drugs like Suboxone or Methadone to ease the effects of cravings. Clare Krusing, with the trade group America's Health Insurance Plans, says when making a decision, insurance plans are looking at effectiveness.

CLARE KRUSING: It's taking into account the patient's health and how they respond to those treatments. There are many cases where if patients need additional care and support, that is provided to them.

ALLEN: Valerie Fiore is skeptical because she says Anthony met the criteria for a longer stay. Deb Beck represents a treatment advocacy group in Pennsylvania. She says she hears stories like Anthony's all the time, and facilities battle insurers to cover longer stays for patients.

DEB BECK: The whole thing about who is worthy to have insurance coverage gets tangled into this. If I had heart - a heart problem and I didn't do everything I was supposed to, I would not be denied coverage. In fact, if I got sicker, you would increase the coverage for me.

ALLEN: Under a 2008 federal law, insurers have to treat drug and alcohol addiction the same as any other medical problem. The Department of Labor says it's investigated 140 claims, and problems have been resolved. But the advocates say the information isn't public, and no fines have been issued. Krusing, with the insurance industry's trade group, says when treatments for addiction are so different from those for medical issues, it's hard to figure out exactly what parity looks like.

KRUSING: When you're comparing those treatment plans, it's essentially comparing apples and oranges. And that's an inherent challenge for health plans and for patients and - and their providers.

ALLEN: But Sam Ball, with CASAColumbia, a group devoted to linking the science of addiction with solutions, says insurance companies should recognize a longer inpatient stay allows people to break away from bad influences.

SAM BALL: It also gives them more time for planning about where they should be living after they get out of treatment. It also gives them more time to be doing more intensive training on coping skills that they'll need once they leave the hospital or the program.

ALLEN: Meanwhile, Valerie Fiore is trying to cope with her son Anthony's overdose death. She sometimes sleeps in his bed.

FIORE: I still cry myself to sleep every night. I don't know. It just makes me maybe feel closer to him.

ALLEN: As she deals with the loss, she's pushing for a change to the Affordable Care Act that would require at least 90 days of inpatient treatment. So far, Fiore has collected more than 30,000 signatures online, with many saying they're endorsing the change for a brother, a friend or themselves. For NPR News, I'm Ben Allen in Harrisburg.

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