National Advocacy Update for Addiction Programs and Professionals, Part II

It’s been close to a decade since the Wellstone/Domenici Mental Health & Addiction Parity Act, yet the spirit of the law has yet to reach its full impact. Federal agencies were slow to issue rules pertaining to the law, and insurance companies and consumers alike fail to grasp the intricacies of the law. 

The Affordable Care Act (ACA) then required all new small group and individual market plans to cover ten essential health benefit categories, including mental health and substance use disorder services, and to cover them at parity with medical and surgical benefits. The ACA did not identify which benefits should be covered; each state chooses an Essential Health Benefits benchmark plan to determine which addiction benefits must be covered by the ACA plans sold in that state.

Parity, like every law, will not be effective unless it is properly implemented and executed. The White House this spring announced the formation of a parity task force, given the charge to promote compliance with parity best practices; support the development of tools and resources to support parity implementation; and develop additional agency guidance as needed to facilitate the implementation of parity. Its deadline for a report is October 31.

When The National Center on Addiction and Substance Abuse at Columbia University reviewed addiction benefits offered in the 2017 Essential Health Benefits benchmark plans, they found more than two-thirds violate the ACA (CASA Columbia, 2016). None of the plans are adequate, the report concluded. People with SUDs are not be receiving effective treatment because insurance plans aren’t covering the full range of evidence-based care. For example, the NCASA review did not find a single state that covered all of the approved medications used to treat opioid addiction.

A study just published in Health Affairs found that insurance financing has not increased for substance use disorder treatment (Mark et al., 2016). Many plans do not cover or restrict access to residential SUD treatment and eating disorder care, even when treating professionals determine a needed length of stay based on clinical criteria, despite covering comparable levels of care for other chronic health conditions. They also do not cover services that help people to manage their disease and maintain wellness, such as mental health and SUD recovery support services.

As part of the Coalition for Whole Health, CCAPP has been mindful of these issues. We are part of a coalition that calls for the federal government to issue additional specific guidance to State regulators and plans on how to implement the federal parity law, identify parity violations, and enforce the law in both public and private insurance. We also believe the federal government should issue additional guidance detailing the parity law’s transparency requirements and modeling for issuers the appropriate disclosure of coverage and plan design information.  Finally, Federal and State regulators should robustly enforce the requirements of the federal mental health and SUD parity law prospectively during plan approval and retrospectively through complaint investigations.

 

Through the work of the Coalition for Whole Health and many of its organizational members, we have seen many critical gaps and restrictions in insurance plan coverage of substance use disorder and mental health care, even when equitable coverage is required by the federal parity law and consumers are paying for what should be comprehensive benefits. Studies have documented many problems. These include deficiencies in most states’ benchmark plans that result in the failure of many essential-health-benefit-based insurance plans to cover services, or the coverage of noncomparable and limited services, including intensive outpatient, residential, and recovery support or chronic disease management services, and medications (LAC, 2016). And even when insurance plans do cover services, they often impose more burdensome obstacles to obtaining that care, including inappropriate denials based on lack of medical necessity, prior notification or authorization and repeated authorizations, Step therapy, and other medical management. Access to care is further hindered by inadequate provider networks that do not include providers that offer the full range of covered services or specialize in adolescent care.  

CCAPP will continue to address these gaps and keep its membership appraised of progress.

Acknowledgements: The author would like to thank the Legal Action Center for their assistance. 

CASA Columbia. (2016). Uncovering coverage gaps: A review of addiction benefits in ACA plans. Retrieved from http://www.centeronaddiction.org/addiction-research/reports/uncovering-coverage-gaps-review-of-addiction-benefits-in-aca-plans

The Legal Action Center (LAC). (2016). Substance use: Parity and health care access resources. Retrieved from https://lac.org/resources/substance-use-resources/parity-health-care-access-resources/

Mark, T. L., Yee, T., Levit, K. R., Camacho-Cook, J., Cutler, E., & Carroll, C. D. (2016). Insurance financing for mental health conditions but not for substance use disorders, 1986–2014. Health Affairs, 35(6), 958–65.