Certain insurance plans are legally required to cover benefits for addiction treatment under the Affordable Care Act (ACA). A new report by Center on Addiction shows that ACA Plans sold in many states in 2017 did not comply with these requirements. The report, Uncovering Coverage Gaps II: A Review and Comparison of Addiction Benefits in ACA Plans, demonstrates the need for policymakers to better implement and enforce laws that are meant to prohibit discriminatory insurance practices and ensure patients and families are able to obtain lifesaving care that is affordable.

“Most patients 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,” said the report’s author, Lindsey Vuolo, Director of Health Law and Policy at Center on Addiction.

In this Q&A, Vuolo explains how the report was compiled, what it found and what it means for families.

What criteria did you evaluate in Uncovering Coverage Gaps II?

This report carefully examines the substance use disorder (SUD) benefits offered by at least one health plan in each state in 2017. These plans are required by the ACA to cover SUD treatment as an Essential Health Benefit (EHB). The ACA does not define the specific treatment services or medications that plans must cover. Instead, each state is allowed to define the minimum benefits that plans must cover by picking an “EHB benchmark plan.” We previously reviewed the 2017 EHB Benchmark Plans and released our findings in our first report, Uncovering Coverage Gaps: A Review of Addiction Benefits in ACA Plans. In this study, we evaluated one to two plans that were offered in each state in 2017, evaluated the plan for compliance with the ACA and assessed the SUD benefit coverage. We also compared the plan’s benefits with the benefits in the state’s 2017 EHB Benchmark Plan. 

What is an Essential Health Benefit (EHB)?

The ACA requires most individual and small group 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 SUD treatment, which must be covered at parity with medical/surgical benefits. While most plans are subject to the federal Parity Act, a decade-old law that prohibits insurance plans from imposing more restrictive standards on MH and SUD benefits than they impose on similar medical/surgical benefits, the Parity Act does not require plans to cover SUD benefits. By requiring plans to cover MH and SUD 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.

What did you discover among these plans? 

• 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.
• Plan documents for plans offered in over 90 percent of the states did not contain sufficient, transparent information to complete an analysis.

Have any improvements been made with regard to coverage for addiction treatment since the last study? 

• We found slight improvement in compliance with the ACA’s requirements to cover SUD benefits. Over two-thirds of the 2017 EHB Benchmark Plans were determined to be noncompliant.
• 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.
• There was an overall, albeit 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 while only a small number of states offered a plan that provided adequate SUD benefit coverage in 2017. Of particular concern, we also found that discriminatory coverage worsened with regard to methadone, the medication that is considered the gold standard for opioid use disorder (OUD) treatment.
• Transparency of information in plan documents worsened. The vast majority of plan documents for the 2017 EHB Benchmark Plans and the 2017 ACA Plans lack critical information. Not only do plan documents lack information essential for our analysis, but they also lack information that is important for consumers to make informed decisions when purchasing and using their insurance.

What does it mean for families?

Families who have insurance that covers addiction treatment should not have to drain retirement and college savings accounts or face financial ruin to pay for care. Families should know that they often have rights when it comes to insurance coverage for addiction treatment and that they should exercise those rights.

We understand the importance of insurance coverage for families and the need to make quality care accessible and affordable. We will continue to do research, provide recommendations, and disseminate information to promote improved benefit coverage. We will be working to create tools and resources for consumers and look forward to sharing more information later this year.