The National Center on Addiction and Substance Use conducted a comprehensive review (UNCOVERING COVERAGE GAPS: A REVIEW OF ADDICTION BENEFITS IN ACA PLANS) of the addiction benefits offered in the 2017 Essential Health Benefits (EHB) benchmark plans. The ACA mandates coverage of substance use disorder services, and requires that these benefits be provided at parity, meaning they must be equal or comparable to medical/surgical benefits. The ACA does not identify which benefits should be covered; instead, each state chooses an EHB benchmark plan to determine which addiction benefits must be covered by the ACA plans sold in that state.
The analysis found that none of the plans provide adequate addiction benefits, and over two-thirds violate the Affordable Care Act (ACA).
- Violates the ACA by not including coverage of at least one opioid reversal agent
- The ACA required coverage of at least one medication in the opioid reversal category as well as at least one medication in the following categories: alcohol deterrents/anti-craving, opioid dependence treatments, and smoking cessation agents
- Parity compliance for SUD benefits could not be determined
- Cost sharing requirements not provided
- Plan documents do not contain specific information about cost-sharing obligations, making it impossible to determine whether there is parity in financial requirements among SUD services and medical/surgical services
- Does not provide comprehensive coverage for SUD
- Does not cover the full array of critical benefits without harmful treatment limitations
- Plan documents silent on methadone coverage
- Explicitly requires prior authorization
- Prior authorization is required for nonemergency inpatient admissions, partial hospitalization, and intensive outpatient treatment
- Plan documents contain insufficient benefit information
- Lacked sufficient detail to fully evaluate the adequacy of SUD benefits
National Trend
- Over two-thirds of plans do not comply with all of ACA’s requirements for coverage of SUD benefits
- 18{c48ccdf3c73afb47c94c61fa7aae86e62bfbb2e57db984400d0c5994c9d92c5c} of plans violate parity requirements, an additional 31{c48ccdf3c73afb47c94c61fa7aae86e62bfbb2e57db984400d0c5994c9d92c5c} contain possible parity violations
- None of the plans contain comprehensive coverage for SUDs
- Plan documents for 88{c48ccdf3c73afb47c94c61fa7aae86e62bfbb2e57db984400d0c5994c9d92c5c} of the 2017 EHB-benchmark plans lack sufficient detail to fully evaluate compliance with the ACA and/or the adequacy of SUD benefits