Insurance plans that cover substance abuse treatment must provide the same level of care and cost sharing as they do for other medical issues, but treatment centers say disagreement over what this means leaves many alcoholics and drug addicts without the coverage they need.
The Mental Health Parity and Addiction Equity Act of 2008 required comparable cost sharing and treatment for major medical needs and mental health and substance abuse when employer-provided insurance included these benefits — and most large company plans do.
As of Jan. 1, the Affordable Care Act then added mental health and substance abuse treatment to its list of essential health benefits that have to be covered in all individual and small business plans. And it can’t be any more restrictive than medical coverage. Final rules dictating how this works came out in November.
“Many providers … report less days and more difficulty with reimbursement since the final rules were established,” says Michael Walsh, CEO of the National Association of Addiction Treatment Professionals. Many providers and insurers disagree “as to what the practical implementation of the rules should be and what should be covered.”
An ongoing NAATP survey of treatment centers shows disputes over what qualifies as a “medical necessity” is behind 63% of denials for treatment coverage since last July. Twenty centers submitted details of 800 cases involving disputes over parity for the survey.
Insurers are often being tougher on what they’ll allow than they were before the new rules, says Ben Brafman, CEO of Destination Hope treatment center in Fort Lauderdale. Addicts or alcoholics who the center’s psychiatrist or licensed addictions professionals say need at least 30 days of in-patient treatment are now often getting up to five days approved and the center has to fight for every additional couple of days, he says.
Susan Pisano, a spokeswoman for the industry trade group America’s Health Insurance Plans, acknowledges that there are “certainly demands placed on health insurers” under the ACA, but she says insurers “are still fully committed, and have always been, to quality of care.”
The National Institute on Drug Abuse’s principles of drug addiction treatment say “no single treatment is effective for everyone,” Pisano points out. The document also notes research shows most patients need at least three months in treatment, but Pisano says that could be in- or out-patient.
“There’s a lot of confusion within the industry on how health care reform is going to be enforced,” says Nate Kasper, a Kansas treatment facility executive who is heading the NAATP study.
A recovering addict living with another addict doesn’t have a safe environment to go home to and may need 90 days to a year of treatment, says Kasper. And some of the young opiate addicts his centers treat often relapse and overdose as soon as they finish short stints of detox.
Diane Schiraldi, a recovering alcoholic whose Aetna plan paid for 45 days at Destination Hope, says nothing would have changed with her drinking after a week or less in treatment.
“Where do they get this timeline from?” asks Shiraldi, a cardiac patient care associate at a hospital. “You need intense therapy to ever get to the root of the issue.”
While uninsured, Schiraldi had such severe digestive problems from drinking vodka on an empty stomach that she ran up $40,000 in bills from emergency room visits — just the kind of costs the ACA was designed to prevent.
“I don’t know that there’s research that says anything about the threshold being 30 days or five days or any number of days in between,” says Pisano. “What insurers are going to do is work with providers on a treatment plan and it’s not going to be the same situation for every patient.”
Aetna spokeswoman Susan Millerick says the company follows the nationally recognized American Society of Addiction Medicine’s guidelines, which “guide our coverage decisions based on the health of each person who needs substance use disorder treatment.”
Aetna is one of the best companies in terms of coverage, says Destination Hope vice president Alton Smith, but some other companies use other criteria or their own internal guidelines.
NAATP’s survey found.89% of disagreements over whether treatment was on par with what would be covered for medical issues such as diabetes or heart disease were related to detox, Inpatient or residential treatment. Destination Hope covers about $750,000 a year of in-patient treatment that insurance companies refuse to cover for clients.
“It still boils down most of the time to the quality of care the insurance company is going to pay for,” says Brafman. “Sometimes they’re just not going to do it.”
Tens of millions of American will have greatly expanded access to mental health and substance abuse treatment under the ACA, says Health and Human Services spokeswoman Erin Shields Britt. She says the agency will work with other agencies to “monitor implementation of this law and to determine appropriate federal action as necessary.”