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

There are numerous barriers to addiction treatment, but cost and lack of insurance coverage are commonly cited reasons people with a perceived treatment need forgo care. In a 2016 report, we examined each state’s 2017 EHB Benchmark Plan – the insurance plans selected by each state to determine which addiction benefits must be covered by the ACA Plans sold in that state. We found that none of the plans provide adequate coverage for addiction benefits and over two-thirds violate the ACA’s requirements.

In 2017, we built on this study by reviewing a national sample of commercial plans modeled on the 2017 EHB Benchmark Plans and sold to consumers on state and federal marketplaces in that same year (the “2017 ACA Plans”).

Key Takeaways

This report found that there were only modest improvements with ACA compliance and benefit adequacy, compared to the 2017 EHB Benchmark Plans. In the midst of an unrelenting opioid epidemic, the majority of states offered plans in 2017 that were non-compliant with the ACA and provided inadequate coverage for addiction benefits. Additional findings included the following:

• More than half of U.S. states offered ACA Plans in 2017 that did not comply with the ACA’s requirements for coverage of SUD benefits. This is a slight improvement from the 2017 EHB Benchmark Plans, more than two-thirds of which were determined to be non-compliant.
• Twenty percent of states offered ACA Plans in 2017 that violated parity requirements. Compliance with parity was unchanged – 18 percent of the 2017 EHB Benchmark Plans contain parity violations.
• One state (Rhode Island) provided comprehensive coverage for SUD treatment in the two 2017 ACA Plans reviewed, while three other states (California, Minnesota and Oregon) offered at least one plan in 2017 that provided comprehensive coverage for SUD treatment. This marks a slight improvement from the 2017 EHB Benchmark Plans, none of which was determined to provide comprehensive coverage for SUD by covering the full array of critical benefits without harmful treatment limitations.
• Of particular concern, the report found that discriminatory coverage worsened with regard to coverage for methadone, the medication that is the gold standard for opioid use disorder treatment. This is problematic given the dire need to expand treatment access and methadone’s demonstrated efficacy for opioid addiction treatment.
• Plan documents continue to lack transparency and specificity about covered SUD benefits. Ninety percent of the 2017 EHB Benchmark Plans and ninety-two percent of states offered ACA Plans in 2017 that were identified as lacking sufficient information about SUD benefit coverage.

Recommendations

For state governments:

• Cover all critical SUD benefits, including all FDA-approved SUD medications.
• Remove harmful/excessive treatment limitations.
• Prohibit the use of intoxication exclusions (a.k.a. Uniform Accident and Sickness Policy Provision Laws, UPPLs).
• Eliminate exceedingly high cost-sharing.
• Ensure compliance in ACA plans.
• Require plan documents to contain sufficient and transparent information.

Research Methods

This report was based on a review of a national sample of individual market plans sold on federal and state marketplaces in 2017. Each 2017 ACA Plan was reviewed to evaluate the SUD benefits and determine whether the plan: (1) satisfied the ACA’s requirements regarding coverage of SUD benefits; (2) complied with Parity Act requirements; (3) offered adequate coverage for SUD benefits by covering the full range of critical SUD services and medications without imposing harmful treatment limitations; and (4) provided enough information in plan documents to sufficiently evaluate compliance and adequacy of benefits.