Starting in 2015, Scottsdale Recovery Center will be able to accept more forms of insurance, including those covered by Obamacare (Affordable Care Act). The extended insurance coverage (to include mental health and addiction treatment coverage) has and will create real changes in Americans’ lives. People struggling with addiction issues may see as many effects as anyone, with some major transformations to addiction coverage beginning this year.
Healthcare’s 2014 Addiction ‘Sea Change’
Provisions of the health care law — better known as “Obamacare,” but officially the Affordable Care Act (ACA) — have been gradually implemented since the legislation’s passage in 2008. Some of the major provisions finally take effect in 2015—for example, people can begin receiving health insurance under the so-called health insurance exchanges this year. Several of the most important aspects of the ACA for the world of addiction also finally roll out in 2014. The federal government, for example, released final regulations in November concerning the ACA’s requirements that mental health and substance abuse treatment receive equal footing with medical health care.
The changes, despite some potential limitations, will mean big differences for addiction coverage in the United States, said Alden Bianchi, an employee benefits attorney who composed a report on the final regulations for the National Law Review. “These rules are…a sea change in the way that health plans approach the coverage of mental health and substance abuse disorder benefits,” he said.
Getting More People Covered
All told, the ACA stands to newly insure some 30 million to 33 million people in the United States, according to Congressional Budget Office estimates.
Coverage thus expanded, the ACA then specifically addresses addiction by regulating what health benefits insurance plans must cover.
Or, as Heller puts it, “Now you have health coverage, which is step one. Step two is, will that health insurance pay for treatment?”
And the ACA represents a massive step forward in getting insurance plans to cover addiction treatment. First, starting this year, the legislation bars insurers from denying coverage due to pre-existing conditions—including substance abuse. But perhaps the most important changes come from the ACA’s expansion of parity rules. In brief, “parity” means that insurance plans must cover mental health and substance abuse treatment at the same level as regular medical care.
In 2008, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA). The law closed up loopholes in a 1996 parity act, now requiring parity in terms of both financial and treatment limitations, Bianchi said. The financial side means deductibles and copays, while treatment parity refers to the number of annual visits and geographic limits for insurance networks.
The rules take great pains to be comprehensive and actually, finally impose real parity, Bianchi said. “The regulators did a very good job with this rule,” he said.
MHPAEA applied to group health and insurance plans, but the ACA incorporates MHPAEA’s parity structure, applying it to the marketplace exchange and Medicaid insurance plans. The healthcare law’s parity effects result, at base, from the inclusion of mental health and substance abuse in the ACA’s list of 10 “Essential Health Benefits.” These 10 items define the areas of coverage that basic health care plans across the country must cover—at parity.
“So, for example, if there are two medications available for a particular condition, or two types of treatment,” you have to have “the same level of treatment available for mental health and substance abuse disorders in that plan,” Heller said.
That requirement will give nearly 32 million Americans new access to substance abuse and mental health treatment, according to estimates from the U.S. Health and Human Services Department. And it will expand mental health and substance abuse benefits for an additional 31 million Americans, the HHS estimates.
“This is a big deal for addiction treatment access,” Heller said.
The Essential Health Benefits framework, unfortunately, does impose some limits on the extent of addiction coverage, Heller said. Defining benchmark plans for each state, that list of 10 benefits requires only “a bare minimum” of addiction treatment coverage, leaving out medication like methadone, Heller said. Expanding benchmark plans to include such medication treatment will require further advocacy, Heller said.
Where It Could Break Down
One aspect of the ACA could be particularly helpful in scaling up—the integration of behavioral health (mental and substance abuse) with physical health. That coordination provides the opportunity to expand addiction treatment in alternative ways, Heller said. “We may not have enough treatment, so how about supporting, for example, community health centers to build out substance use disorder treatment?”
And the basic regulations, too, could fail to meet expectations, as insurance agencies may try to skirt the rules. For instance, some have pointed out that insurance plans could violate the spirit of the parity laws via pre-authorization rules. Essentially, both medical and behavioral benefits could call for pre-authorization—but, in practice, only the mental and substance abuse treatments would require it, Bianchi said.
Still, despite the challenges, the ACA and its associated regulations will make a tremendous difference, particularly among those populations disproportionately affected by substance abuse.
“I think that the ACA is an absolute game changer,” Donner said. “And I’m extremely excited about the potential of it.”
One of the most important changes in the ACA may come from its larger philosophical implications, Heller said. Essentially, President Obama’s health care act enshrines in federal law that substance abuse is a medical issue—not the result of poor morals, and not a criminal justice problem, Heller said.
That reflects a greater societal change, as the country as a whole has gotten over some of the stigma it once held for substance abuse, Bianchi said. “This is a shift that has taken place over generations,” he said. “It’s not just a matter of a couple of years and a couple of laws.”
The ACA’s federal definition of addiction as a healthcare issue may even pave the way to greater changes, potentially including decriminalization, Heller said.
“If we view ACA as this document that is now federal policy…it’s sort of de facto recognition that it’s not a criminal justice issue. It needs to be addressed as a health issue.”
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