Uncovering Coverage Gaps II: A Review and Comparison of Addiction Benefits in ACA Plans | Center on Addiction

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

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

Published: March 2019

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BACKGROUND

Lack of access to effective treatment is a major contributor to soaring overdose rates. There are numerous barriers to addiction treatment, but cost and lack of insurance coverage are commonly cited reasons people with a perceived treatment need forgo care. Federal and state laws require certain insurance plans to cover substance use disorder (SUD) treatment. The Affordable Care Act (ACA) requires plans sold on federal and state marketplaces (the “ACA Plans”) to cover SUD treatment benefits as an Essential Health Benefit (EHB). SUD benefits must be covered in accordance with the Parity Act, a federal law that requires insurance plans to pay for addiction treatment the same way they cover treatment for other chronic diseases, like diabetes or cancer.

In a 2016 report, we examined each state’s 2017 EHB Benchmark Plan – the insurance plans selected by each state to determine which addiction benefits must be covered by the ACA Plans sold in that state. We found that none of the plans provide adequate coverage for addiction benefits and over two-thirds violate the ACA’s requirements.

In 2017, we built on this study by reviewing a national sample of commercial plans modeled on the 2017 EHB Benchmark Plans and sold to consumers on state and federal marketplaces in that same year (the “2017 ACA Plans”).

METHODS

We reviewed a national sample of individual market plans sold on federal and state marketplaces in 2017. Each 2017 ACA Plan was reviewed to evaluate the SUD benefits and determine whether the plan: (1) satisfied the ACA’s requirements regarding coverage of SUD benefits; (2) complied with Parity Act requirements; (3) offered adequate coverage for SUD benefits by covering the full range of critical SUD services and medications without imposing harmful treatment limitations; and (4) provided enough information in plan documents to sufficiently evaluate compliance and adequacy of benefits.

KEY FINDINGS

We determined there were only modest improvements with ACA compliance and benefit adequacy, compared to the 2017 EHB Benchmark Plans. In the midst of an unrelenting opioid epidemic, the majority of states offered plans in 2017 that were non-compliant with the ACA and provided inadequate coverage for addiction benefits.

Key findings and highlights from the report include:

  • More than half of states offered ACA Plans in 2017 that did not comply with the ACA’s requirements for coverage of SUD benefits. This is a slight improvement from the 2017 EHB Benchmark Plans, more than two-thirds of which were determined to be non-compliant.
  • Twenty percent of states offered ACA Plans in 2017 that violated parity requirements. Compliance with parity was unchanged – 18 percent of the 2017 EHB Benchmark Plans contain parity violations.
  • One state (Rhode Island) provided comprehensive coverage for SUD treatment in the two 2017 ACA Plans reviewed, while three other states (California, Minnesota and Oregon) offered at least one plan in 2017 that provided comprehensive coverage for SUD treatment. This marks a slight improvement from the 2017 EHB Benchmark Plans, none of which was determined to provide comprehensive coverage for SUD by covering the full array of critical benefits without harmful treatment limitations.
  • Of particular concern, the report found that discriminatory coverage worsened with regard to coverage for methadone, the medication that is the gold standard for opioid use disorder treatment. This is problematic given the dire need to expand treatment access and methadone’s demonstrated efficacy for opioid addiction treatment. 
  • Plan documents continue to lack transparency and specificity about covered SUD benefits. Ninety percent of the 2017 EHB Benchmark Plans and 92 percent of states offered ACA Plans in 2017 that were identified as lacking sufficient information about SUD benefit coverage.

CONCLUSION

Despite improved insurance coverage under the ACA and requirements for plans to cover SUD benefits, the majority of people in need of addiction treatment are still unable to obtain care. Unquestionably, more needs to be done to increase treatment capacity and access to evidence-based care, but improving insurance coverage will save lives. Important tools such as the ACA’s EHB requirement and the Parity Act continue to be underutilized. Failing to use these tools undermines other legislative or funding initiatives and exacerbates the current addiction crisis. More must be done to guarantee that insurers are fulfilling their obligation to address our country’s addiction crisis by providing services for a disease that is both preventable and treatable.

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