The majority of state insurance plans violate Affordable Care Act requirements for addiction treatment coverage, and state benchmark plans provide inadequate coverage, according to a new report from The National Center on Addiction and Substance Abuse.
The mental health community had celebrated the Affordable Care Act’s mandate that substance use disorder treatment receive coverage equal to that for other chronic diseases — obligations referred to as parity requirements.
However, researchers say the minimum benefits that states require insurers to meet fall short of the standard for effective treatment, which can lead to devastating consequences.
“If a patient’s insurance plan does not cover treatment, the out-of-pocket cost may be so prohibitively expensive that the patient forgoes care,” lead author Lindsey Vuolo told DrugRehab.com. “This can result in continued substance use, overdose or death.”
Vuolo and a team of researchers at CASA analyzed each state’s 2017 essential health benefit-benchmark plans — outlines of the minimum level of substance use disorder coverage required of ACA plans sold in the state.
They found that more than two-thirds of the plans contained obvious violations of ACA requirements. Other key findings included:
The researchers also wrote that none of the plans comprehensively covered a full array of benefits without limitations. The most frequently excluded benefits were residential treatment and methadone maintenance therapy for opioid addiction. Many plans could also make timely treatment difficult to access.
“Even if some treatment is covered, when plans make it harder to access the treatment, for example by requiring prior authorization before treatment begins, it can turn people away,” Vuolo said. “Addiction affects the parts of the brain associated with motivation, decision making, and impulse control, so a patient’s window of motivation to engage in treatment may be narrow.”
Without enforcement, the ACA does little to help patients get treatment. States are getting away with the lack of coverage because they don’t suffer consequences for violating the federal law.
“The ACA does not have any penalties for non-compliance,” Vuolo said. “In theory, the penalty is that a plan that contains violations cannot be approved by regulators to be sold in the state. But the report findings confirm this does not always happen: many of the plans we reviewed were sold to patients in 2014 and contained violations.”
The Affordable Care Act requires individual and small group plans to cover substance use disorder treatment as one of 10 essential health benefits. In doing so, the plans:
The authors of the report detailed an example of how substance use disorder services should compare to services for other common diseases in order to meet parity requirements.
If a patient has Type 2 diabetes, his insurance plan covers emergency care for diabetic shock, inpatient hospital care for a foot amputation, outpatient care or follow-up appointments and a variety of Type 2 diabetes medications.
So, if a patient has an opioid use disorder, he should be covered for emergency care after an overdose, inpatient detox and rehab, follow-up outpatient therapy and methadone or buprenorphine medication.
ACA plans also have to follow federal guidelines for a variety of services.
For tobacco screening and cessation, ACA plans must cover:
For alcohol and drug use screening and treatment, ACA plans must cover:
ACA Plans must cover at least one drug in every category and class listed in the U.S. Pharmacopeia Medicare Model Guidelines. There is one therapeutic category for substance use disorder medications and four classes. The classes include:
The ACA does not define which substance use disorder services must be covered. The U.S. Department of Health and Human Services uses a benchmark approach that allows each state to develop its own definition.
The states select an employer-sponsored plan that covers each essential health benefit and is non-discriminatory to serve as the benchmark. The benchmark plan defines the essential health benefits and serves as a template for ACA plans.
The CASA researchers evaluated the benchmark plans that were recently adopted by all 50 states and the District of Columbia. Their goal was to determine if the plans met ACA requirements for substance use disorder benefits, complied with parity requirements, provided adequate care for addiction treatment and provided enough information for evaluation.
Their findings included:
The report also identified several limitations that prevent patients from receiving comprehensive addiction coverage, including:
Vuolo said the states should review and revise their benchmark plans to comply with ACA requirements and ensure the plans comprehensively cover substance use disorder treatments without limitations.
“We hope that this report raises awareness about the rights that patients have to addiction treatment,” Vuolo said. “We would also recommend that patients who are denied coverage of addiction treatment services by their plan appeal those decisions.”