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:
- 18 percent of plans violated parity requirements.
- 31 percent of plans contained potential parity violations.
- 88 percent of plans lacked sufficient detail to evaluate parity compliance or ample coverage of addiction benefits.
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.”
What Insurance Plans Are Required to Cover
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:
- Have to cover preventative services and prescription drugs.
- Cannot impose lifetime or annual dollar limits.
- Must comply with the Mental Health Parity and Addiction Equity Act of 2008.
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.
Tobacco Screening and Cessation
For tobacco screening and cessation, ACA plans must cover:
- Four counseling sessions.
- One 90-day treatment regimen of any approved medication.
- Medication such as bupropion, varenicline, or nicotine replacement therapy.
Alcohol and Drug Use Screening
For alcohol and drug use screening and treatment, ACA plans must cover:
- Assessments for patients at risk for substance use disorders.
- Screening for alcohol abuse.
- Brief counseling interventions.
- Alcohol and drug use assessments for 11- to 21-year-olds.
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:
- Alcohol medications, including acamprosate, naltrexone, disulfiram.
- Opioid dependence treatment medication, such as buprenorphine, naltrexone and buprenorphine in combination with naloxone.
- Opioid reversal agents such as naloxone.
- Smoking cessation agents, including bupropion, varenicline and nicotine replacement.
Substance Use Disorder Services
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.
A Long List of Violations
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.
CASA researchers’ findings included:
- 50 percent of plans violate the requirement for tobacco cessation coverage.
- 45 percent of plans violate the requirement for coverage of prescription drugs to treat addiction.
- 11 plans lack enough detail to evaluate compliance with the ACA’s requirements.
- Two plans violate the ban on lifetime dollar limits on benefits.
- One plan violates the requirement for coverage of substance use disorder services.
The report also identified several limitations that prevent patients from receiving comprehensive addiction coverage, including:
- 100 percent of the plans lack sufficient coverage for prescription drugs to treat opioid addiction.
- 64 percent of the plans require prior authorization for a range of services.
- 60 percent of the plans lack sufficient coverage for tobacco cessation.
- 40 percent of the plans exclude coverage of critical substance use disorder treatment and management services.
- Nine plans have overly restrictive treatment limitations.
- Four plans have excessively high cost sharing requirements.
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.”