As the nation faces a deadly opioid epidemic, four leading nonprofits in the addiction field -The National Center on Addiction and Substance Abuse, the Legal Action Center (LAC),
Among the first collective initiatives of the new Addiction Solutions Campaign (ASC) will be a major effort to secure equitable insurance coverage for addiction treatment, which consumers are entitled to under the Mental Health Parity and Addiction Equity Act of 2008 (Parity Act). The Parity Act requires equitable coverage of substance use disorder and mental health benefits in both the public and private health insurance markets. The Act also mandates that health insurance plans' standards for substance use and mental health benefits be comparable to, and be no more restrictive than, the standards for other medical/surgical benefits. With vigorous enforcement, the Act should effectively prevent discriminatory insurance coverage for those with mental health and substance use disorders.
In-Depth Analysis: Parity Enforcement Framework Insufficient to Determine Parity Compliance
The ASC completed a recent, in-depth analysis of publicly available documents for seven major health plans offered in 2015 and 2016 in the small and large group markets in
While the current enforcement framework primarily relies on consumers to raise issues with parity compliance, the analysis found that consumers are not provided with sufficient information by insurance plans to determine what treatment benefits they are eligible for and what barriers exist to accessing those benefits. In 5 of the 7 plans reviewed for this analysis, it was not evident from the insurance contract or the Schedule of Benefits that the plan under review covered all the critical benefits to treat substance use disorders. Further, consumers are not informed of their rights under the Parity Act nor are they provided with enough information regarding the processes and instructions for filing a parity complaint.
The analysis also found that state insurance regulators do not have sufficient information from insurance companies to confirm that their policies comply with the Parity Act. Neither consumers nor regulators, whose responsibility it is to protect consumers, can identify most Parity Act violations from plan documents routinely reviewed for plan approval and provided to consumers.
The lack of transparency in plan documents, coupled with the lack of clear processes and instructions for filing a parity complaint, put consumers at a severe disadvantage for being able to assert their rights under the Parity Act.
"At a time when effective treatment for opioid addiction in the
Opioid Epidemic at Alarming Levels, Significant Treatment Barriers Still Exist
Current enforcement of the Parity Act has failed to close the staggering addiction treatment gap and millions of Americans in need of treatment remain unable to access it. A 2016 report in Health Affairs(1) found that private insurance companies covered only 18 percent of treatment for substance use disorders compared with 35 percent for all health expenditures.
According to the latest data available from the
Should there be an overhaul of the Affordable Care Act (ACA), the potential loss of substance use disorder treatment coverage for millions of families could be even greater.
"It is clear today that even as 144 Americans die every day from a drug overdose related death, we are still struggling to address an unprecedented epidemic of substance use disorders, and that the requirements of the Parity Act are still not being met," said Samuels. "The current enforcement system is flawed and some families are paying the ultimate price. Families often don't know what their coverage is, or how or where to complain."
A Complaint-Driven System: Puts Burden on Policyholders at Most Vulnerable Time
Currently, parity enforcement depends on individuals notifying regulators about potential violations and appealing coverage denials. Consumers must engage in a burdensome complaint-driven process to secure the coverage to which they are entitled. Often this is happening for parents and families while they are in a crisis with a loved one who is struggling with addiction, and when denial of care can be deadly.
"Getting clear, direct information from insurers is difficult," said Williams. "As for our family, we were not aware of the Parity Act. What became William's fatal overdose occurred four days after he was denied in-patient detox that was deemed 'not medically necessary.' Would obtaining parity intervention immediately upon his denial have resulted in a lifesaving admission within four days? Could a complaint have been successfully resolved in that short time? We'll never know."
To achieve better compliance, the ASC is advocating for specific recommendations to shift the current enforcement framework from consumer complaints to prospective regulatory review. The ASC recommends that insurance regulators obtain a 'Parity Transparency and Compliance Report' from insurers documenting that they are responsive to the Parity Act's standards so that they may conduct comprehensive plan review prior to approval.
Specifically, the ASC recommends that:
* Plans should be required to submit their internal analyses to demonstrate that coverage is compliant with the Parity Act, including identification of all specific limitations on benefit scope or access to services, such as pre-authorization requirements or ''fail-first" policies.
* As part of review for Parity compliance, Regulatory Agencies should evaluate the scope of prescription drug coverage for mental health and substance use disorder treatment and utilization management requirements.
* Regulatory Agencies should develop model contracts that fully describe substance use and mental health benefits, align standards with Parity Act requirements and inform consumers of their rights under the law.
* Regulatory Agencies should enhance the provider community's capacity to identify potential Parity Act violations and advocate for plan compliance in network adequacy and rate setting standards.
"Critical details about coverage and access to treatment are often missing from plan documents. It would be challenging - if not impossible - for an average consumer to know whether a plan violates the Parity Act," said Samuels. "Yet, the current system relies on consumers to report problems to insurance regulators. When regulators don't receive complaints, they assume the plans are in compliance. Our analysis reveals that most parity violations cannot be identified through consumer complaints nor can they be identified via form review. We need to shift our approach so that plans are demonstrating compliance BEFORE they are marketed to consumers. Regulators can and should demand this information."
This prospective regulatory review would relieve consumers of the nearly impossible burden of identifying Parity Act violations and asserting their right to care in the midst of a health crisis. In order to document the challenges that consumers have in accessing addiction treatment coverage and call for a systemic change in the enforcement framework, the Addiction Solutions Campaign is encouraging parents and families to sign a petition to help enforce the Parity Act.
Methodology for In-Depth Analysis
A team of highly qualified researchers from