Uncovering Coverage Gaps: A Review of Addiction Benefits in ACA Plans

    Published: June 2016

    This comprehensive review of the addiction benefits offered in the 2017 Essential Health Benefits (EHB) benchmark plans found that none of the plans provide adequate addiction benefits, and over two-thirds violate the Affordable Care Act (ACA).

    The ACA holds great promise for expanding access to addiction treatment. The law mandates coverage of substance use disorder services, and requires that these benefits be provided at parity, meaning they must be equal or comparable to medical/surgical benefits. The ACA does not identify which benefits should be covered; instead, each state chooses an EHB benchmark plan to determine which addiction benefits must be covered by the ACA plans sold in that state.

    Key Takeaways

    Nearly all of the 2017 EHB benchmark plans were non-compliant with ACA requirements and/or provided inadequate coverage of addiction benefits.

    Findings included the following:

    • Over two-thirds of the plans contained facial (obvious) violations of the ACA’s requirements for coverage of addiction benefits.
    • Eighteen percent of the plans lacked compliance with parity requirements; 31 percent of the plans contained possible parity violations.
    • None of the plans provided comprehensive coverage for addiction by covering the full array of critical benefits without harmful treatment limitations; the most frequently excluded or not explicitly covered benefits were residential treatment and methadone maintenance therapy.
    • Plan documents for 88 percent of state plans lacked sufficient detail to fully evaluate parity compliance and/or the adequacy of addiction benefits.

    Recommendations

    For the government:

    • Cover all critical SUD benefits.
    • Cover all FDA-approved SUD medications.
    • Remove excessive treatment limitations.
    • Prohibit the use of Uniform Individual Accident and Sickness Policy Provision Laws (UPPL).

    Published

    June 2016

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