At the same time, the proportion of enrollees in the largest managed care companies who received outpatient or emergency department care for mental health doubled, from an average of 9.4 percent in 2013 to 20.8 percent in 2014, according to an analysis of the 2015 Consumer Report Card on Health Insurance Carriers in Connecticut, issued by the state Insurance Department. The percentage of members who received inpatient mental health care also doubled, although it remained low, with most companies providing inpatient services for less than .5 percent of all enrollees.

The rise in rejections by the state’s 10 largest indemnity managed care companies – private health insurers, not including Medicare or Medicaid — came as state officials focused on improving mental health outreach and treatment, in the wake of the Sandy Hook school shooting in December 2012. The managed care organizations include companies such as Aetna Life Insurance Co., Anthem Health Plans, CIGNA Health and Life Insurance Co., and UnitedHealthcare Insurance Co.

The Insurance Department report shows that the 10 largest insurers rejected an average of 8.5 percent of behavioral health claims in 2014 – up from 5 percent in 2013. Some of those rejections were appealed and ultimately reversed, the data show.

While behavioral health rejections rose, the percentage of denials of all health services requests to the major insurers dropped slightly over the two years, the data show.

Daniela Giordano, public policy director for the Connecticut chapter of NAMI (National Alliance on Mental Illness), said the data showing a rise in rejections for behavioral health services is “not a surprise. We hear it from families on a weekly basis.”

Although Connecticut has a mental health parity law, which requires health insurers to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than those applied to medical or surgical benefits, “That doesn’t mean the law is being implemented the way it should be,” Giordano said. Requests for treatment are often denied because insurers say they lack “medical necessity,” she added, but “it’s not clear what ‘medical necessity’ means, or what criteria they’re using to justify denying” a service.

Keith Stover, a spokesman for the Connecticut Association of Health Plans, said the good news in the state report is that “the number of people accessing mental health services is increasing. I think everyone from the (insurance) industry to providers to advocacy groups views that as a positive.”

Of the rise in rejections, he said, “I would be cautious about generalizing about this kind of a blip,” adding that the data are an “imperfect snapshot” that do not explain reasons for rejections. The annual reporting on behavioral health is being expanded this year, to include additional information on authorization and denials of coverage by type and level of treatment, state Insurance Department officials said.

Stover said managed care plans have been actively involved in improving behavioral health access and reporting.

“There will always be some ‘hot spots’ (in coverage decisions),” he said. “The payers are very much in a place now where, if there are hot spots, they want to know about them,” he said.

Victoria Veltri, the state’s healthcare advocate, said “It is always a concern for me when the overall aggregate denial rate increases.” But she added that the reasons for the jump in behavioral health denials remains unclear without more detailed data, noting that 2014 was the first year of operation of Access Health CT, the state’s health insurance marketplace.

“Many people on open enrollment experienced some challenges with eligibility for services,” she said. “Given the changes, we would need to dig deeper to explain the increase reported . . . There were many variables at play.”

Veltri said the increase in utilization in both inpatient and Emergency Department mental health services was “not surprising, given increased access to coverage, awareness, and challenges with finding community-based providers.”

Donna Tommelleo, a spokeswoman for the state Insurance Department, said the agency collects the data annually so that it can be shared with consumers and analyzed by the department for any irregularities.

“This is a tool we have to look at trends. If we find any troubling practices, our market conduct division will review it” and take action, if needed, she said.

The 2015 report shows that, on average, more than 70 percent of patients in managed care plans who were discharged from an inpatient facility had a follow-up visit with a mental health practitioner within 30 days, in both 2013 and 2014. The average length of a mental health stay in a hospital or treatment facility fell slightly, from eight days in 2013 to six days in 2014.

The report also shows that a larger proportion of enrollees in the top managed care plans received treatment for alcohol and drugs in 2014 than in 2013. While an average of .44 percent of enrollees had received inpatient chemical-dependency treatment in 2013, that nearly tripled to 1.2 percent in 2014. The proportion receiving outpatient or emergency department treatment for drugs or alcohol also increased, from 1.16 percent in 2013 to more than 3 percent in 2014, the data show.

Two plans, Golden Rule Insurance Co. and HealthyCT, had the highest percentage of their members receiving outpatient or emergency department drug and alcohol treatment, while Golden Rule and UnitedHealth had the highest percentage receiving inpatient care.

The report also ranks the largest managed care insurers on a number of quality measures, such as cancer screening and preventive care. CIGNA, Connecticut General and ConnectiCare had the highest percentages of enrolled women, ages 52 to 74, who received mammograms between October 2012 and December 2014 – all above 76 percent, compared to an average of 60 percent. UnitedHealth, Connecticut General and CIGNA had the highest percentages of members, ages 51 to 75, who received screenings for colorectal cancer. ConnectiCare, CIGNA and Connecticut General had the highest proportion of members diagnosed with hypertension whose blood pressure was adequately controlled during 2014.

In the area of preventive care, Connecticut General, CIGNA and Anthem had the highest percentage of enrollees, ages 45 to 64, who had at least one preventive care visit with a health plan provider between 2012 and 2014 – all above 96 percent. The average for all managed care plans was 75 percent.

The report also includes member surveys, which have enrollees rating the managed care organizations on how well they meet needs. For the question, “How often did you get an appointment with a specialist as soon as you needed?” Aetna and Anthem received the highest percentage of “always” and “usually” responses, while Golden Rule and Time Insurance Co. received the lowest. For “How often was it easy to get care, tests or treatment you needed through your health plan?” Aetna, CIGNA and HealthyCT got the highest percentage of “always” and “usually” responses, while Golden Rule and Time got the least.

The survey found that about a quarter to a third of consumers in most plans were not satisfied with their prescription drug coverage, for reasons ranging from high co-payments, to drugs not included in a plan’s formulary.

“There is no public resource in Connecticut that makes (comparison) pricing information available to consumers. That means there’s no consumer protection against egregious pricing behaviors by providers,” said Francois de Brantes, executive director of the Health Care Incentive Improvement Institute in Newtown, which partnered with Catalyst for Payment Reform to publish the “Report Card on State Price Transparency Laws.”

The Report Card’s scores reflected a state’s overall legislative effort toward health care price transparency, with states that post price information on a public website receiving more points than those that release a report or provide data to consumers only upon request. The organizations that developed the report card are nonprofits that support payment reforms to increase the quality and value of health care.

Ellen Andrews, executive director of the Connecticut Health Policy Project, said, “The score is totally warranted. Our state laws have been really behind when it comes to price transparency. We get calls from people on our hotline about this issue all the time.”

“Consumers are told to shop around for health care, but it’s really an impossible thing to do,” said Andrews.

Only two states – Massachusetts and New Hampshire – received an “A.” Both states have All-Payer Claims Databases (APCD) which systematically collect and aggregate claims from commercial insurers and public insurers (Medicare and Medicaid). Connecticut is working to establish a claims database by next year.

The claims database offers consumers true comparison pricing information unlike the report released in May by the U.S. Department of Health and Human Services that details the amounts hospitals charge Medicare for the 100 most common treatments and procedures.

Connecticut laws require health care facilities to report total charges (gross revenue) and total payments (net revenue) to the Office of Health Care Access (OHCA) in the state Department of Public Health (DPH). These total amounts are not specific to particular procedures. In addition, OHCA posts the current “pricemaster” – a detailed price list for supplies, services and pharmaceuticals – that hospitals can include on a detailed patient bill. Consumers can ask OHCA to verify hospital charges upon request.

DPH spokesman William Gerrish said the state’s grade “seems undeserved’’ because consumers have access to some pricing information on the OHCA website and through the Freedom of Information Act.

Price transparency is more important than ever because a growing number of consumers face greater out-of-pocket expenses with high-deductible health plans. “These high-deductible health plans are placing a great financial burden on individuals and families,” said de Brantes. “The cost of every health care service matters because it’s coming out of consumer’s pockets.”

Experts expect the use of high-deducible health plans to grow. Forty-four percent of the nation’s major employers are considering offering high-deductible health plans as the only benefit option to employees in 2014, a recent PwC Touchstone Survey found. Seventeen percent of all employers now offer high-deductible health plans as the lone benefit option for employees – a 31 percent increase over 2012.

The shift to high-deductible health insurance plans is part of a national trend, according to Kevin Counihan, chief executive officer of Access Health CT, an online marketplace that will begin selling health insurance plans in October with coverage effective Jan. 1, 2014, as a result of health care reform. He calls the trend the “401K-ing” of the health insurance industry, a reference to the move by employers to replace defined pension plans with 401K plans that require employees to make investment decisions.

“That’s increasingly occurring in health care. Employers are going to give a defined contribution of money to their employees and employees will be using an exchange, whether it’s private or public, to buy health insurance,” he said. The trend is “great for employers because they can fix their budgets. But most employees aren’t experienced or trained to make health insurance decisions, just like they aren’t trained or experienced to make decisions about investing their pension money. Yet they are forced to do it.”

Meantime, Connecticut’s all-payer claims database is a little over a year away from implementation, said Counihan. Access Health CT received a $6.6 million grant through the Affordable Care Act to implement the large-scale database that collects medical, dental and pharmacy claims from commercial insurers and public insurers such as Medicare and Medicaid. Consumers will have access to the data in a free web-based portal.

“Establishing the all-payer claims database is an important step to making (health care) cost and quality information more transparent,” said Counihan.

The claims database will be available August 2014 with future reports becoming “increasingly more substantive” in subsequent years, said Counihan.  Although the data won’t be available in time for this fall’s open enrollment season, Connecticut is proceeding at a fast clip, he said. “It takes most states two to five years to implement an all-payer claims database. Ours will be up and running in 15 months.”

Both the Connecticut Hospital Association and the Connecticut Association of Health Plans support the state’s efforts to implement an all-payer claims database. “We have been actively engaged in the planning and development of the APCD since the very first meeting and have been working closely with the technical folks involved to make sure that it will work and that the information is useful and useable,” said Keith Stover, spokesman for the Connecticut Association of Health Plans.

Michele Sharp, director of communications and public affairs for the Connecticut Hospital Association, said “Connecticut hospitals support efforts to make pricing more transparent and meaningful for consumers.” She encouraged consumers to contact insurers for cost information. “Transparency on the part of insurers will help consumers understand their payment obligations,” she said.

Stover said insurers in Connecticut “feel very strongly that better health outcomes are achieved when members have good and readily accessible information.” He said health plans currently offer “robust member portals” that help consumers access information about benefits and providers.

For now, consumers can find some cost information by checking the Centers for Medicare & Medicaid Services report on the prices hospitals charge Medicare. (Find the data by clicking here.)

But, that report raised questions about how hospitals set prices and why they differ so widely. For example, Yale-New Haven Hospital charged Medicare an average of $85,902 for a cardiac pacemaker implant, compared to $22,096 at Manchester Memorial Hospital. The average price charged Medicare for a lower joint replacement ranged from $72,393 at Greenwich Hospital to $23,063 at Charlotte Hungerford.

“Consumers deserve to have as much information about the quality and price of their health care as they do about cars, restaurants and appliances,” said de Brantes.