Insurance coverage creates hurdles for patients to access substance abuse treatment

A new report calls for changes by insurers and regulators to help ensure patients can access treatment for substance use disorders.

While federal law requires equitable insurance coverage for addiction treatment, patients still face hurdles to access care despite the country’s ongoing opioid epidemic, according to a new report.

The Mental Health Parity and Addiction Equity Act of 2008 has not put an end to restrictive coverage and limited reimbursement for substance use treatment in either private insurance or Medicaid, according to the report from the Addiction Solutions Campaign (ASC).

The group, a collaboration of four nonprofit organizations in the addiction field, recently completed an in-depth analysis of seven major health plans offered in 2015 and 2016 in the small and large group markets in New York and Maryland. The Parity Act requires a health plan’s standards for substance use and mental health benefits be comparable to, and no more restrictive than, the standards for other medical benefits.

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The data suggests the law hasn’t ended the battle for coverage, however, the study found. “These payers shift the cost of care to state and local governments and deny many consumers the healthcare benefits that they pay for in private health plans or are entitled to receive through their Medicaid managed care plan,” the group said in an overview (PDF) of its findings.

The analysis found that patients are not provided with sufficient information by insurance plans to determine what treatment benefits they are eligible for or that the plan covers benefits to treat substance use disorders. And patients are not informed of their rights under the Parity Act or told how to file a complaint.

The report recommends changes including that health plans demonstrate their coverage is compliant with the law and that regulatory agencies take steps to ensure that is the case.

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The American Medical Association said in a statement that it hopes the report will spur insurers and regulators to take action to increase patient access to treatment. “This report makes it clear that health insurers and regulators need to take a hard look at their legal obligations to ensure that patients receive the full benefits of existing parity laws covering mental health and substance use disorders,” said Patrice A. Harris, M.D., chair of the group’s Opioid Task Force, in the announcement. 

“While we recognize that some insurers have made steps to remove prior authorization for medication-assisted treatment, for example, this report should be a wake-up call that too many patients face significant hurdles in accessing care,” she said. Otherwise, if patients are forced to delay or interrupt treatment because of a health plan utilization management coverage restriction, it can mean relapse or death from overdose for patients with an opioid use disorder.