Illinois Health Plans Frequently Deny Coverage of Mental Health, Addiction Care, According to New Report; Lawmakers Pledge to Investigate

Despite ongoing mental health and addiction crises, Illinois treatment providers responding to a recent survey report frequent claims denials and other barriers to coverage, according to a new report released today by The Kennedy Forum Illinois, Illinois Psychiatric Society, Illinois Association for Behavioral Health, Illinois Association of Rehabilitation Facilities, the Community Behavioral Healthcare Association of Illinois, the Illinois Health and Hospital Association, and Health and Medicine Policy Research Group.

The 16-page report, which is available here, raises important questions about health plans’ coverage of mental health and addiction conditions. Further investigation is urgently needed to identify and remove barriers, and ensure that Illinois Medicaid managed care organizations (MCOs) and commercial insurance plans are in compliance with federal and state laws that require they cover mental illness and addiction care on par with care for other medical conditions.

Key report findings include:

  • Upwards of 75 percent of responding providers reported that Medicaid MCOs sometimes/often/always denied coverage for inpatient treatment, partial hospitalization, intensive outpatient treatment, and medication-assisted treatment. Nearly half of responding providers reported commercial insurers at least sometimes denied inpatient treatment.
  • More than 60 percent of responding providers reported that Medicaid MCOs sometimes/often/ always refused to cover the requested level of care and instead approved only a lower level of care, while 54 percent of responding providers reported commercial insurers did the same.
  • With Medicaid MCOs, nearly 65 percent of responding providers reported that they were told often or always that networks were simply closed. Nearly half of responding providers were told this often or always with commercial plans. The result: with mental health and addiction care providers unable to join plan networks, patients have more difficulty accessing care, due to the narrow network.                 
  • More than 90 percent of responding providers report that both Medicaid MCOs and commercial plans have refused to provide requested medical necessity criteria, despite clear legal requirements that plans do so.

The organizations responsible for the…

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