By james art Many California families are still struggling to get mental health treatment four years after Gov. Gavin Newsom signed a landmark law requiring health insurance plans to provide enrollees with all medically necessary mental health and addiction treatment.
A new investigation by CalMatters mental health reporter Jocelyn Wiener found that the mental health denial appeals system remains effectively broken:
- Research shows that most people never appeal denials of treatment to their health plans; advocates say that the faction that does so often ends up being rejected again.
- Regulators don’t have the data to track doctors’ decisions. They are not authorized to routinely require health plans and health insurers to provide information on how often they deny treatment, nor do they have access to the records of individual doctors who make those denials.
- When government regulators do step in, they overwhelmingly side with patients. For 2023 and the first eight months of 2024, for appeals related to residential treatment denials, the Department of Managed Health Care reversed health plans’ medical necessity decisions 76 percent of the time.
Jocelyn’s story chronicles a family’s quest for healing as their son struggles to overcome addiction. Ryan Matlock died at age 23, shortly after his insurance plan refused to continue covering his stay at an addiction treatment center, according to his family and a lawsuit they filed in San Bernardino Superior Court.
“He was just a number” in the health plan, said his mother, Christine Dougherty of Yucaipa.
She is suing OptumHealth Behavioral Solutions of California, which declined to comment on Matlock’s case and said in a statement that “health plan coverage decisions are made in accordance with the terms of the member’s health plan and federal and state laws, and with the help of evidence-based clinical guidelines and peer reviews.”
State lawmakers have been eyeing the law since 2020. Last session, Sen. Scott Wiener introduced Senate Bill 294, which would require automatic review when commercial health plans deny mental health treatment to children and young adults. The Senate passed the bill in January, but it was held up in the House Appropriations Committee in August.
“The fact that we even have to consider this bill is an indictment of the system,” the San Francisco Democrat said.
Treatment decisions can be difficult, and no one disputes that insurance plans should not recommend that patients move to lower and less expensive levels of care.
“That’s the hardest part, telling someone, ‘Do you want to take a chance?’ How suicidal do you think you are?” said Dr. Alexis Seagan, inpatient medical director at UC Irvine Medical Center and immediate past chair of the California State Psychiatric Association’s Committee on Governmental Affairs.
Read more about it in Jocelyn’s story. And find out what you can do if you’re denied coverage in this handy guide.