Background
On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (?ACA? or ?the Act?) into law.1 While the ACA is aimed primarily at improving health outcomes by increasing access to health insurance, it also contains a number of provisions targeted at improving health through other means. This short paper discusses three that are likely to improve access to programs and services to prevent and treat substance use disorder (SUD).2 One makes such services part of the ?essential benefit? package that most plans covering newly insured people will be required to offer. The second requires that these benefits be provided at parity with medical and surgical services, while the third prohibits insurers from refusing to cover people with a history of SUD.
The Essential Health Benefits Requirement
Many insurance plans, particularly those available to lower income people, provide poor or no coverage for SUD treatment.3 The ACA changes that. Beginning January 1, 2014, the health insurance plans offered to most newly insured (and many currently insured) people must provide ?essential health benefits.?4 Among these essential benefits is coverage for mental health and substance use disorder services.5 The Department of Health and Human Services (DHHS) will issue guidance and regulations that will provide specifics as to the scope of these benefits.6 At DHHS? request, the Institute of Medicine will make recommendations on the criteria and methods for determining and updating the essential health benefits package.7
These essential health benefits must be part of the coverage offered by all qualified health plans within health insurance exchanges.8 State-sponsored basic health programs and small group and individual plans offered outside of an exchange must meet the standard as well, as will plans covering most persons enrolled under the expanded Medicaid coverage rules that will go into effect in 2014.9
The Substance Use Disorder Parity Requirement
The ACA improves access to substance use disorder services by extending a federal law that requires that SUD benefits be provided at parity with medical and surgical benefits to most people who will gain insurance under the Act. All plans offered through exchanges and all benchmark and benchmark-equivalent Medicaid plans will be required to comply with this law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA).10 While the MHPAEA does not apply to traditional fee for service Medicaid, it does apply to Medicaid plans operated by managed care organizations.11
The MHPAEA was enacted in 2008 as part of a larger piece of legislation, the Emergency Economic Stabilization Act of 2008.12 It builds on and extends a 1996 law, the Mental Health Parity Act (MHPA).13 The MHPA took a first step in the direction of parity by prohibiting group health plans from imposing annual or lifetime dollar limits on mental health benefits except to the extent that such limits were also imposed on medical and surgical benefits.14 While the MHPA did improve access to services for some mental health conditions, SUD benefits were excluded from its reach.15
The MHPAEA improves on the MHPA in several respects.16 It extends the scope of covered conditions to include SUD and prohibits plans that offer both medical/surgical benefits and SUD benefits from charging higher deductibles or copayments for SUD services than those charged for medical/surgical services.17 It also prohibits plans from limiting the number or frequency of provider visits for SUD except to the extent that those limits are also imposed on substantially all medical and surgical benefits and requires that plans that provide out-of-network medical/surgical benefits also provide out-of-network SUD treatment.18 Finally, regulations promulgated under the MHPAEA require that health plans that offer benefits for a specific substance use condition in any one of six classifications (inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; emergency care; and prescription drugs) also provide benefits for that condition in every other classification in which medical/surgical benefits are offered.19
The Prohibition on Pre-existing Condition Exclusions
Federal law does not currently prohibit health insurance plans from denying coverage to persons with a history of substance use disorder or from charging such persons prohibitively high premiums. The ACA tackles this problem in two ways. First, it requires the establishment of Pre-existing Condition Insurance Pools (PCIPs) to enroll persons who have been uninsured for at least six months and are having difficulty enrolling in insurance plans because of a pre-existing condition.20 These PCIP plans will terminate on January 1, 2014, when a broad exclusion on denying coverage on the basis of pre-existing conditions will go into effect.21
Beginning in 2014, group health plans and issuers that offer group or individual health insurance coverage are prohibited from denying coverage to people over the age of 18 because of pre-existing conditions or discriminating against individuals who have a history of illness.22 This prohibition goes into effect for enrollees under age 19 for plan years beginning on or after September 23, 2010.23 The provision also prohibits individual and small group policies from charging higher rates because of an enrollee?s health status. 24 Additionally, most insurers will be prohibited from imposing lifetime and annual limits on the dollar value of essential health benefits.25
Other Provisions Affecting Substance Use Disorder Prevention and Treatment
Other ACA provisions could potentially impact SUD services in less direct ways. For example, beginning in 2011 states will have the option to amend their state Medicaid plans to incorporate ?health homes? for individuals with chronic conditions.26 Substance use disorder is specifically listed as a chronic condition, and states that pursue this option are required to consult and coordinate with the Substance Abuse and Mental Health Services Administration to address ?issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions.?27 The health home model is designed to increase collaboration between providers and coordinate disease prevention and management in a way that is more responsive to the patient?s needs. Since SUD treatment particularly for those with concurrent conditions is often hampered by lack of coordination between providers, such a health home may improve the quality of care such people receive.
Many other ACA provisions may be helpful in the prevention and treatment of SUD as well.28 For example, some SUDs begin with improper or inadequate pain treatment or attempts to self-medicate depressive disorders.29 The ACA provides funds to advance research and treatment for pain care and allocates funding for better pain care treatment.30 It also creates Centers of Excellence for Depression and provides over one billion dollars of funding for research into and treatment of depressive disorders.31 Additionally, the ACA establishes several funding streams for investment in prevention programs, which should include the prevention of SUD.32 Although there is no direct funding stream for SUD treatment, it is not inconceivable that grants under some of these funding initiatives could be used for SUD treatment if evidence exists that such treatment prevents other diseases and conditions.
Conclusion
The ACA should improve access to treatment for substance use disorders in a number of ways. Chief among these are the extension of health insurance including SUD coverage to many previously uninsured people and requirements that most health plans covering these newly insured people provide coverage for SUD at parity with medical and surgical care, together with a ban on refusing coverage to persons because of a previous SUD diagnosis. Many other aspects of the ACA should also work to help prevent and treat SUD, and some funding may be available to prevent its occurrence.
For further information, please contact: Corey Davis
www.healthlaw.org
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