Article
Uncovering the Major Gaps in Insurance Coverage
Research from the Partnership to End Addiction
The Partnership to End Addiction conducted a research study to answer this question: "Are all American families with insurance plans under the Affordable Care Act (ACA) getting the benefits required by law for substance use treatment?" They found that the answer was a "resounding no". Plans sold under Obamacare or the Affordable Care Act in 2017 were often out of compliance with two major laws:
Essential Health Benefits (EBH)
According to the Partnership to End Addiction, "The ACA requires most individual and small group insurance 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 Substance Use Disorder (SUD) treatment, which must be covered at the same level as other medical or surgical benefits."
The Parity Act
"The federal Parity Act is a 10-year-old law that says insurance plans are not allowed to place more restrictions on mental health and substance use disorder benefits than they place on similar medical or surgical benefits. (It’s important to note, though, that the Parity Act does not actually require plans to cover substance use disorder treatment.)
By requiring plans to cover mental health and substance use disorders 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."
Findings from the Research
The Partnership to End Addiction examined the substance use disorder (SUD) benefits offered by at least one ACA plan in each state in 2017. The results were startling.
>50%
Over half of the states offered a plan in 2017 did not comply with the ACA’s requirements to cover SUD benefits.
20%
Twenty percent of the states offered a plan in 2017 that violated the Parity Act.
1
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.
>90%
Over 90 percent of the plans reviewed did not contain sufficient, transparent information to complete an analysis.
The research from the Partnership notes a slight improvement in ACA compliance compared to previous reports, but over two-thirds of plans are still non-compliant. Many states still violate the Parity Act. Despite an overall small improvement in SUD benefit coverage, none of the plans provided comprehensive coverage without harmful treatment limitations. Moreover, discriminatory coverage worsened for methadone, a key medication for opioid use disorder treatment. Transparency in plan documents remained poor, lacking critical information for informed decision-making by families.
What Can Families Do?
The Partnership to End Addiction provides this advice to families and encourages them to know t heir rights and have a strategy to "fight back" if coverage is denied. Here is their advice:
- 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.
- Learn what to ask about substance use on your first call with your insurance provider
- Learn how to properly document your contact with your insurance company
- Learn how to file an insurance appeal for substance use disorder when you’re denied coverage
- Learn how to file an insurance parity complaint if insurance denies your claim
Read this valuable advice by accessing the full article and research at www.drugfree.org.
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