Are all American families with insurance plans under the Affordable Care Act (ACA) getting the benefits required by law for substance use treatment?
That’s the main question we wanted to answer in our report, Uncovering Coverage Gaps II: A Review and Comparison of Addiction Benefits in ACA Plans. The answer is a resounding “no,” demonstrating the need for policymakers to better protect families from discriminatory practices and enforce the law.
We know that most loved ones and their families cannot afford or receive care if it is not covered by their insurance plan. Improving insurance coverage for addiction treatment is essential to resolve the opioid crisis and move toward an approach where we finally treat addiction as the disease it is.
Before examining where plans sold in 2017 fell short of providing treatment coverage, it’s helpful to understand some lingo — mainly, Essential Health Benefits (EHB) and the Parity Act.
Essential Health Benefits (EHB)
The ACA requires most individual and small group insurance plans, meaning the plans that individuals purchase on the state or federal marketplace (commonly known as “Obamacare Plans”), to cover 10 categories of benefits known as the Essential Health Benefits (EHB). One of the EHB categories is mental health (MH) and Substance Use Disorder (SUD) treatment, which must be covered at the same level as other medical or surgical benefits.
The federal Parity Act is a 10-year-old law that says insurance plans are not allowed to place more restrictions on mental health and substance use disorder benefits than they place on similar medical or surgical benefits. (It’s important to note, though, that the Parity Act does not actually require plans to cover substance use disorder treatment.)
By requiring plans to cover mental health and substance use disorders benefits as an EHB, in addition to complying with the Parity Act, the ACA provides the strongest protections for consumers seeking care covered by insurance. The more than 10 million people who purchase these plans pay for and are entitled to coverage for SUD treatment.
How were 2017 ACA Plans reviewed for substance use disorder benefits?
In Uncovering Coverage Gaps II, we examined the substance use disorder (SUD) benefits offered by at least one ACA plan in each state in 2017. Instead of telling states what kind of coverage they must offer for SUD benefits, each state is allowed to choose an EHB benchmark plan that defines the minimum benefits offered in that state. (We previously released a report on SUD benefit coverage in the 2017 EHB Benchmark Plans.)
In reviewing each plan, we asked the following questions:
- Does the plan comply with the ACA’s requirements to cover SUD benefits? In addition to the ACA’s requirement to cover substance use treatment benefits, the ACA also requires plans to cover smoking cessation services and certain alcohol and drug screenings for adults and adolescents, as well as certain medications for addiction treatment.
- Does the plan comply with the Parity Act? Because of limitations in the information we’re able to access for the study, we conducted a limited review for parity compliance. Nonetheless, we were able to identify obvious instances where the benefits for substance use treatment were not equivalent to surgical or medical benefits, as well as “red flags” for potential parity violations in the plans we reviewed.
- Does the plan cover SUD benefits that provide adequate care for SUD? It’s not enough to just cover SUD — we know that quality treatment is difficult to come by. We carefully reviewed the services and medications covered by each plan to determine whether the plan provides the full range of treatment options for SUD. We also reviewed any limitations imposed by the plan (such as limits on the number of treatments or prior authorization requirements) to determine whether the plan places unnecessary limits or barriers on the care families’ loved ones receive.
- Does the plan provide enough information to even determine if it meets the requirements of the ACA and Parity Act, as well as information to evaluate the SUD benefits? The plan documents must provide detailed information about the specific SUD benefits that are covered and applicable cost-sharing requirements (e.g. deductibles, co-pays and co-insurance) and treatment limitations. It’s also essential for families who are purchasing insurance to have detailed descriptions of the SUD benefits and limitations, so they can know whether a plan will pay for specific health services and medications.
How well do these ACA plans cover substance use disorder treatment?
- Over half of the states offered a plan in 2017 that did not comply with the ACA’s requirements to cover SUD benefits.
- Twenty percent of the states offered a plan in 2017 that violated the Parity Act.
- Only one state provided comprehensive coverage for SUD treatment in both plans reviewed while three other states offered at least one plan in 2017 that provided comprehensive coverage for SUD treatment.
- Over 90 percent of the plans reviewed did not contain sufficient, transparent information to complete an analysis.
Have any improvements been made to coverage for addiction treatment since the last study?
- There was slight improvement in compliance with the ACA requirements to cover SUD benefits from the previous report. While over two-thirds of the 2017 EHB Benchmark Plans were determined to be noncompliant, more than one-half of states still offered a plan in 2017 that was non-compliant with ACA requirements.
- Unfortunately, compliance with the Parity Act was virtually unchanged. Nearly the same number of states were identified as having a parity violation in their 2017 EHB Benchmark Plan as before.
- There was an overall (though small) improvement in SUD benefit coverage. None of the 2017 EHB Benchmark Plans were determined to provide comprehensive coverage for SUD by covering the full array of critical benefits without harmful treatment limitations. Only a small number of states offered a plan that provided adequate SUD benefit coverage in 2017.
- Discriminatory coverage got worse with regards to methadone, one of the medications that is considered the gold standard for opioid use disorder treatment.
- Transparency of information in plan documents didn’t change. The vast majority of plan documents lack critical information for families to make informed decisions when purchasing and using their insurance.
What can families do about these gaps in insurance coverage?
Put pressure on policymakers to help enforce the law. The ACA and the Parity Act are both federal laws that provide strong protections on paper. But, they are meaningless if not well implemented and enforced. We need advocates like you to put pressure on policymakers to help enforce the law and create greater access to affordable, quality care.
Know what rights you have when it comes to finding insurance coverage for addiction treatment, and how to fight back:
Unquestionably, more needs to be done to increase treatment capacity and access to evidence-based care, but improving insurance coverage will save lives.