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EHB benchmark plans come up short in addiction coverage

June 9, 2016
by Tom Valentino, Senior Editor
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Despite the passage of the Affordable Care Act (ACA) and parity laws designed to bring addiction treatment benefits in line with those found in medical and surgical coverage, major gaps continue to exist in 2017 Essential Health Benefits (EHB) benchmark plans across the nation, according to a National Center on Addiction and Substance Abuse (CASA) study published this week.

The EHB benchmark health insurance plan identified in each state serves as a de facto minimum coverage floor for all ACA plans.

CASA reviewed the addiction benefits offered in the 2017 EHB benchmark plans for all 50 states plus Washington, D.C.. Among the findings:

  • More than two-thirds of the plans are in violation of the ACA;
  • 18% of plans violate parity requirements, with 31% containing potential parity violations;
  • None of the EHB benchmark plans provide comprehensive coverage for substance use disorders (SUDs) by covering the full array of critical benefits without harmful treatment limitations; the most frequently excluded or not explicitly covered benefits are residential treatment (not covered in 14 states’ plans) and methadone maintenance therapy (not covered in 7 plans);
  • 88% of plans lack sufficient detail to fully evaluate ACA compliance.

Researchers were both disheartened and, at times, surprised by their findings, Lindsey Vuolo, CASA associate director of health law and policy and the study’s lead author, told Behavioral Healthcare in an email.

“There was a lot of hope that the ACA would significantly improve access to addiction treatment because it mandates coverage of addiction services and requires parity,” Vuolo said. “We were surprised by the number of plans that are violating the ACA’s requirements and excluding critical benefits. The fact that no plans cover all the FDA-approved medications to treat opioid addiction was particularly surprising given the current opioid epidemic.”

In its current form, the ACA does not have penalties for plans not in compliance. Many of the plans reviewed for the CASA study were sold on state exchanges in 2014, and, as benchmark plans, are templates for plans that will be sold in 2017. Vuolo said CASA hopes to see greater enforcement from state and federal regulators.

In its 61-page report, the center called on states to revise their EHB benchmark plans “to comply with the law and ensure comprehensive coverage of evidence-based SUD benefits without harmful treatment limitations,” arguing that it would help patients seeking medically necessary care and decrease health costs in the long term. It recommended 11 measures, including:

  • Covering all critical SUD benefits and FDA-approved SUD medications;
  • Removing harmful and excessive treatment limitations;
  • Prohibiting the use of Uniform Individual Accident and Sickness Policy Provision laws;
  • Eliminating exceedingly high cost-sharing;
  • Issuing additional parity guidance on requirements for prior authorization, coverage of intermediate services and copayment
  • Revising plan documents with insufficient benefit information.

“We saw exclusions of effective and cost-saving benefits, particularly residential treatment and methadone,” Vuolo said in her email. “There is no medical justification for excluding these treatments.

“In addition, treatment limitations such as visit limits, high cost sharing and prior authorization may cause patients to be unable to access care when they need it. Addiction is a chronic, relapsing disease and affects the parts of the brain associated with motivation, decision making, risk/reward assessment and impulse control, so engaging and retaining patients can be difficult. Treatment limitations should be as unrestrictive as possible to ensure patients can access care when they need it.”

Tom Valentino is Senior Editor for Behavioral Healthcare.

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