Drugs are killing us, literally and financially. The Centers for Disease Control (CDC) reports that “opioids (including prescriptions opioids and heroin) killed more than 33,000 people in 2015, more than any year on record. Nearly half of all opioid overdose deaths involve a prescription opioid.”[1] Abuse of tobacco, alcohol and illicit drugs costs our country over $700 billion every year, as reported by the National Institute on Drug Abuse (NIDA).[2]
A recent article in Money, written by Elizabeth O’Brien, highlights the struggle of a family fighting their daughter’s addiction to heroin. Maddie Vail and her parents not only had to contend with her addiction, but also had to fight their insurance company’s refusal to pay for Maddie’s stay in a rehabilitation facility. Maddie’s 20-day stay in a highly-recommended facility resulted in costs of $34,186. The Vail’s insurance carrier denied payment because the family did not receive pre-certification for Maddie’s stay, a virtual impossibility as she was rushed to rehab after being hospitalized for an overdose. The Vails eventually hired an insurance appeals advocate who helped them recover about 40 percent of the costs of Maddie’s subsequent, three-month stay at a step-down facility.[3]
Parity Laws Level the Playing Field
Several laws are on the books to help families like the Vails. One group, The Kennedy Forum, has been instrumental in passing legislation to ensure people with mental illness and addiction are given the same rights as patients with other illnesses. Of particular importance is the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). This bill, “…was the signature achievement of Rep. Patrick Kennedy’s 16 years in Congress. Its passage was the culmination of perseverance over many years to overcome institutionalized insurance discrimination against persons with mental illnesses and substance use disorders.”[4]
MHPAEA and other parity laws require health insurance companies to provide the same coverage that they would other health issues. For instance, as reported in an article this past Fall in The New York Times, “A White House task force on Oct. 27 said insurers need to understand that coverage for the treatment of drug addiction must be comparable to that for other conditions like schizophrenia, cancer and heart disease. As an example, the administration said, insurers may not require prior approval for drugs to treat opioid addiction, like buprenorphine, if they do not impose similar restrictions on drugs with similar safety risks that are prescribed for physical illnesses.”[5]
The MHPAEA statute provides that plans cannot apply financial requirements or treatment limitations to MH/SUD benefits that are more restrictive than those applied to medical/surgical benefits. Further, plans cannot apply separate treatment limitations only to MH/SUD benefits. Most notably, the law aims to remedy both the financial (“quantitative”) and non-financial (“non-quantitative”) limitations that plans may place on addiction and mental health care services if those limitations are not also placed on physical medical services.[6]
Parity Is Gaining Momentum
Just this past November, the Surgeon General’s office issued a Report on Alcohol, Drugs, and Health. It is remarkable that two of the five key components listed as reasons for the development of the report are:
- Improved access to evidence-based treatment services, integrated with mainstream health care, for those at risk for or affected by substance use disorders
- Recovery support services (RSS) to assist individuals in maintaining remission and preventing relapse[7]
It is important for health plans to fully understand parity laws. RegQuest is an easy-to-use service that details medical management regulations. As a subscriber, you gain instant access to up-to-date information on utilization management (UM), external review (ER) as well as grievance and administrative appeals. With a mouse click you can review state surveys, trend reports, blogs and more.
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[1] CDC. “Injury Prevention & Control: Opioid Overdose.” Retrieved from: https://www.cdc.gov/drugoverdose/index.html
[2] NIDA. “Trends & Statistics.” Retrieved from: https://www.drugabuse.gov/related-topics/trends-statistics
[3] Elizabeth O’Brien, “They Fought A Daughter’s Heroin Addiction and Their Insurer, at the Same Time,” Money, Dec. 21, 2016, http://time.com/money/4590546/insurance-claims-denial-addiction-mental-health/?xid=frommoney_soc_socialflow_twitter_money
[4] The Kennedy Forum. For more information, please see: https://www.thekennedyforum.org/parity
[5] Robert Pear, “US Enforcing Insurance Law to Help Fight Opioid Abuse,” The New York Times, Nov. 7, 2016, https://www.nytimes.com/2016/11/08/us/mental-health-parity.html?_r=0
[6] CCIIO. The Mental Health Parity and Addiction Equity Act. Retrieved from https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaca_factsheet.html
[7] U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016, p. 1 -3, https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf