The insurance company insisted my son needed to fail at treatment before providing coverage

“Fail-first” policies put patients at unnecessary risk for suffering a fatal overdose while trying to get coverage for treatment.

By Carole Kelder

We had to battle with our insurance company. I have a good job, I have great insurance that was covering my son at the time, and they would not approve him to go into a treatment center.

They actually told us that he needed to fail twice before treatment would be covered. It’s like playing Russian roulette. How many times does someone need to overdose?

Carole’s story is taken from an interview transcript and has been edited for clarity.

The Problem

“Fail first” policies require a patient to fail treatment at one level of care first, or to fail a specific therapy or medication, before they can begin the recommended course of treatment. These types of policies not only betray best practices for treating substance use and addiction, but may also violate the Parity Act if they are only applied to substance use disorder benefits or are more restrictive than policies imposed on comparable medical benefits.

The Solution

Prohibit health insurers from imposing fail first requirements on substance use disorder benefits.

Take Action

Consolidated Appropriations Act, 2023 strengthened parity enforcement

Send a letter to your members of Congress thanking them for passing the Consolidated Appropriations Act, 2023, which includes provisions to strengthen parity enforcement, including state grants for parity compliance and enforcement.

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