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

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

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

Published: June 2016

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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. 


We reviewed each state’s 2017 EHB-benchmark plan to determine whether the plan: (1) satisfies the ACA’s requirements regarding coverage of addiction benefits; (2) complies with parity requirements; (3) provides adequate care for addiction by covering the full range of critical benefits without imposing harmful treatment limitations; and (4) provides enough information to fully evaluate compliance and adequacy of benefits. 

Recommendations and Conclusions

Our review revealed that nearly all of the 2017 EHB benchmark plans were non-compliant with ACA requirements and/or provided inadequate coverage of addiction benefits. 

Key findings of the paper included:

  1. Over two-thirds of the plans contained facial (obvious) violations of the ACA’s requirements for coverage of addiction benefits
  2. 18 percent of the plans lacked compliance with parity requirements; 31 percent of the plans contained possible parity violations
  3. 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
  4. Plan documents for 88 percent of state plans lacked sufficient detail to fully evaluate parity compliance and/or the adequacy of addiction benefits

In order to fulfill the ACA’s intent of dramatically expanding access to addiction treatment, states should revise their EHB benchmark plans to comply with the law and ensure comprehensive coverage of evidence-based addiction benefits without harmful treatment limitations. This will help to close the addiction treatment gap, improve the health of patients seeking addiction treatment, and decrease costs for the health plans in the long-term.


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