Health insurance plans have traditionally offered little in the way of addiction treatment coverage, so many cheered when the Affordable Care Act (ACA) declared that such benefits should be an essential part of the policies sold through state marketplaces.
But as a new report from the National Center on Addiction and Substance Abuse demonstrates, the provision is far from living up to its promise. In fact, “despite being required to do so under the ACA, insurance plans nationwide aren’t covering the necessary services for people with addiction,” said the study’s lead author, Lindsey Vuolo, JD, MPH, the Center’s associate director of health law and policy.
A key problem, she explained, is that while the ACA mandated the benefits and ordered them to be at parity with other medical services, it didn’t spell out exactly what benefits should be covered. Instead, “it was left to states to build on that foundation by defining the types of services that were going to be required,” Vuolo said.
States do this by crafting “essential health benefits” (EHB) benchmark plans that then become the minimum level of coverage that their ACA plans must offer. But, as the report noted:
“Predictably and regrettably, decisions on what coverage to offer are not informed by what research shows to be the amount and duration of treatment needed to help addicted people get on a path of recovery. A ‘minimum level of coverage’ almost never translates into an effective level of service for what are often very complex and chronic disorders.”
In its report, the Center made a detailed analysis of state benchmark plans created for the 2017 marketplace and summed up the results in a word: “disheartening.”
Among the findings:
- More than two-thirds of the plans contained violations of the ACA’s coverage requirements and 18% violated parity requirements.
- None of the plans offers truly comprehensive coverage without also imposing harmful limits. For example, residential addiction treatment is often completely left out of the picture, and none of the plans covered all of the FDA-approved medications currently available to treat opioid addiction.
Topping it off, “the level of benefit details in plan documents is woefully inadequate across the board,” Vuolo said. A full 88% of the benchmark plans the Center reviewed, in fact, were so vague that they couldn’t be fully evaluated. “And the documents that we reviewed are the documents insurance plans give to members,” she noted, “so they should provide thorough, comprehensive and easy-to-understand benefit information so members are able to quickly understand what their plans cover when they’re seeking addiction treatment. They shouldn’t have to waste time and energy trying to figure it out.”
Some states were markedly better overall than others, Vuolo said. Minnesota, Missouri, Maine and Washington, D.C., for example, had some of the clearer information as well as more complete coverage. On the other end of the spectrum, Alaska covered only emergency detoxification, she said. “And detox only treats the withdrawal symptoms, not the underlying disease of addiction. So in that state, there are really no [ACA-covered] services relating to the treatment of addiction.”
How have states and insurers been able to get away with providing less than was intended by the ACA and parity laws? There’s currently no penalty for noncompliance, Vuolo noted, “and the fact that we found so many violations suggests to us that there’s a lack of enforcement going on.”
The Center shared its findings concerning the various noncompliance and inadequacy issues with the states, Vuolo said, but the proposed plans were largely adopted as written nonetheless. An exception was Indiana, she said, which wrote to tell the Center that its recommendations had caused them to rethink their residential treatment and medication coverage. In light of the relative lack of state response, however, “we thought it would be helpful to combine all our findings into one report so that patients and advocates could see details about the level of coverage offered in their state.” The report can be downloaded from the Center’s website.
The information can help those in need of addiction care act as their own advocate with their insurance companies. “Appeal decisions, and get medical documentation from your doctor,” Vuolo advised. “There are also different advocacy organizations working across the country on these issues that are willing to assist patients and their families access care.” (For more advice, see 4 Tips for Making the Most of Your Mental Health and Addiction Treatment Benefits.)
Looking ahead, Vuolo said, the Center’s hope is that states will get on board with embracing full and comprehensive addiction insurance coverage that recognizes the complexity of treating substance use disorders.
“Addiction is a chronic disease that often goes untreated, and when individuals can’t access addiction treatment, this leads to disability or premature death,” she said. “We’re calling on states to amend their EHB benchmark plans to comply with the law and to cover the full range of critical benefits that are necessary to treat and manage addiction.”
Doing so, she noted, isn’t just the right thing to do, it’s the smart thing to do, because the easier it is for people to get the care they need, the more likely it is they will find their way to recovery rather than become a drag on services.
“Health plans don’t always think in terms of long-term costs, and there is likely some sort of initial upfront cost to offering treatment, but that argument only goes so far,” Vuolo said, “because it’s far more expensive to treat addiction when it’s an acute episode such as an overdose. It is very cost effective for the plans to offer effective treatment.”
By Kendal Patterson
Follow Kendal on Twitter at @kendalpatterson
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