Good afternoon, I am a constituent of Assembly Member Timothy S. Grayson and State Senator Bill Dodd. I am 52-years old and a bookkeeper and accountant for our family business, a small auto collision repair center, in Contra Costa County.  Our business offers our employees medical insurance through California Choice Benefit Administrators.  I have an Anthem Blue Cross Gold Advantage - small group PPO plan that includes substance abuse benefits.  This plan is regulated by the Department of Managed Health Care.

 On September 18, 2021 I entered a state-licensed residential treatment facility, Summit Estate Recovery Center, in order to deal with my long history of doctor prescribed opioids, (due to 20 years of chronic pain), also self-medicating with alcohol for depression and anxiety.  The stress of the pandemic had made my situation worse because the auto repair industry is an “essential business.” We remained open throughout the pandemic and I had to struggle to find and apply for PPP loans, purchase PPE supplies, and keep up with the constantly changing Covid-19 requirements. Our business operations drastically changed during this time. In addition, both of my parents were diagnosed with cancer during the pandemic.

 The amount Anthem would reimburse for each day of substance abuse treatment was much less than what the facility charged, I borrowed money from my parents to pay for treatment.  The facility agreed to give me a superbill so I could be reimbursed the maximum my policy offered.  I calculated that I would get back approximately 25% of what I paid.

 I detoxed for 5 days and then began residential treatment.  After 11 days of residential treatment, the facility applied for an additional 7 days which to my great surprise was denied by Anthem.  I was shocked.  So was my clinical team.  My therapist said that according to the guidelines for addiction treatment, I needed those additional days because I was still at high risk of relapse.

 I can honestly say I was not ready to leave.  At that point in my recovery I was cloudy -not able to put thoughts together, read, comprehend, or deal with emotions.  If I had gone home then, I would have relapsed immediately. The Anthem denial completely derailed my recovery for a day. I remember that day sitting with a recovery friend crying. And later calling my husband from the center still crying.

 After 28 days at the recovery center, 17 days more than Anthem would cover, I stepped down to Intensive Outpatient care which I personally paid for on October 15 and discharged on November 12, 2021. Anthem has not reimbursed any of this care either. I now have over 7 months of sobriety.  I work hard at it every day. I daily attend alumni meetings, AA meetings, Dharma meetings, and read books about sobriety and anti-inflammatory diets.

 To sum things up, I received a superbill for all days of treatment including the 28 days at the center of inpatient care and the 28 days of outpatient care.  I submitted the superbill to Anthem, but I have never been reimbursed by Anthem for even a single day. I have called Anthem many times regarding the claim and each time I get an unclear answer as to why the claim is being denied. Each person I have spoken to tells me a different reason for the denial of payment and that need to wait an additional 30 to 45 days for a decision after the claims are reviewed. The reimbursement should not be this difficult. The claims are submitted with Anthem authorization numbers for the days that were authorized, and I should not have to keep calling to be told by a representative that the claim has been denied and sent for adjustment and to wait 30 to 45 days, even though online the claim says denied.

I am a constituent of State Senator Dave Cortese and Assemblyman Evan Low, sponsors of SB 999, and am well-known to the staff of Summit Estate Recovery Center where I spent 90 days in treatment: 3 days in detox, 24 days in residential level of care, 63 in two different levels of outpatient.

At the time of treatment, I had a fully funded PPO plan through my husband’s employer. In 2020 it was administered by Collective Health and priced by Anthem Blue Cross which also provided medical authorizations. It is regulated by DMHC.

It had no limit on substance abuse treatment provided there is medical necessity.

I entered residential treatment on June 29, 2020. I had been drinking daily for two years before the onset of the pandemic and subsequent “shelter in place” order by Santa Clara County on March 16, 2020. I live alone and during the “shelter in place” my drinking escalated quickly which led to me seeking residential treatment. Anthem authorized residential treatment from June 29-July 8, 2020, and then denied additional residential treatment authorization from July 9-July 26.

It was clear to me, and to the staff who diagnose according to strict addiction guidelines, that it was negligent on Anthem’s part to discharge me back to the house where I live by myself and where my alcohol abuse had escalated prior to admission, during a world pandemic.

According to the denial received from Anthem the decision was made based on criteria that does not apply to substance abuse, but to mental health which is quite different. I continued to experience depression, anxiety, a general state of uneasiness and dissatisfaction with my life and was still suffering from PTSD. Anthem also did not take into consideration that I suffer from Celiac disease, have a Mitral Valve Prolapse of my heart, and in the past have experienced thyroid issues, all making me more susceptible to contracting COVID19 – well before we had vaccines and boosters. In short, I had a weakened immune system.

It is well documented and widely published that addiction is a chronic brain disease. Isolation is extremely dangerous for addicts in early recovery. It is inconceivable that Anthem doctors decided about my health and well-being without considering the totality of my condition. It is astonishing that Anthem determined that instead of remaining in 24/7 residential treatment, attending remote outpatient groups three days a week, for three hours a day would keep me sober.

I decided to pay for the denied days and appeal to Anthem later.

On July 26, eighteen days after Anthem denied additional residential treatment, I felt strong enough to return home and engage in remote outpatient three days a week, three hours a day.

Staying in residential treatment for 28 days was the correct decision for my physical health, my mental health and my sobriety.

Today I have 1 year and 9 months of sobriety.

My husband pays a large premium each month for our PPO plan. We rarely use the benefits. The one time I needed the benefits I was denied essential coverage. After I felt stable enough to write a coherent appeal, I asked Anthem to override their denial and also pay the remaining days I was in residential treatment.

Inexplicably Anthem overrode their doctor’s denial only for four of the denied days and still needs to pay for 13 additional days of treatment. The days they paid were not sequential. It is the equivalent of saying a patient with stage 4 leukemia is only sick on Monday, Wednesday, and Fridays, but not on Tuesday, Thursday, and Saturdays,

I am troubled by the audacity of the insurance system in the way these types of medical situations are handled. Their treatment of me created additional anxiety, stress, and feelings of being overwhelmed as my benefits were cut. I was forced to make a decision that affected my financial security. It is ironic that the institution that is supposed to help with medical situations exacerbates the medical problem. Additionally, the way my appeals were handled is indicative of typical insurance tactics to wear the insured down by misleading, roadblocking, changing out case managers and diversion in the hopes that the insured will give up out of frustration, confusion, and exhaustion. I refuse to cave to their tactics and will continue to fight to get what is owed to me.