Template Language for Protecting Your Rights Under the Federal Mental Health Parity and Addiction Equity Act and Other Federal Laws

Passed in 2008, the Mental Health Parity and Addiction Equity Act prohibits discrimination in health insurance coverage of substance use disorder (SUD) and mental health benefits.  113 million people have gained the protections of the federal parity law. Other Federal and state laws protect your right to have good coverage in your health insurance plan, and insurance companies with more information about these laws and the science of addiction treatment should provide better coverage of the services that are proven to work.

The Coalition for Whole Health has created template language for you to use or modify when you advocate for good coverage of substance use services and medications in your private health insurance, Medicaid, or other public health plan.

 

 

Coalition for Whole Health Template Language to Use If:

  • The parity provisions of the ACA require that MH/SUD benefits be provided in no more restrictive way than other medical/surgical benefits covered by the plan. Financial requirements and treatment limitations imposed on MH/SUD benefits, including the processes plans use to determine which services are medically necessary, must meet the federal parity requirements.
  • Prior to the ACA, the federal parity law (MHPAEA) did not require small group or individual plans to meet the parity requirements. However, by requiring coverage of MH and SUD benefits as one of the Essential Health Benefit (EHB) categories and extending the federal parity law requirements to those plans, Congress mandated that all public and private plans subject to the EHB, inside and outside insurance Exchanges, be required to offer MH and SUD benefits, at parity with the medical/surgical benefits offered by the plan. This requirement was reiterated by the Department of Health and Human Services (HHS) in the EHB rule.
  • Based on a review of available plan information, PLAN X appears to have a number of parity violations.

INSERT INFORMATION ABOUT YOUR STATE PLAN’S FINANCIAL REQUIREMENTS/TREATMENT LIMITATIONS HERE, EXAMPLES FOLLOW BELOW:

For example, the plan documents state that, “Substance abuse rehabilitation programs are limited to one per benefit period.” Similar treatment limitations do          not appear to be applied to any other medical/surgical services covered by the plan. This treatment limitation represents a clear violation of the parity law and       cannot be allowed to be imposed on the plan’s SUD benefits in PLAN X.

Visit limits are applied to MH and SUD services but are not applied to other corresponding levels of care for other illnesses. Both MH and SUD outpatient    services have 30-day visit limits for the benefit period. The plan doesn’t apply any similar treatment limits to other covered outpatient medical services.

Additional information is necessary to conduct a complete parity analysis. The plan documents also state that limits and maximums apply for MH/SUD services but fail to specify those limits, making it impossible to determine whether those treatment limitations comply with the federal law.

  • As a highly effective medication to assist in the treatment of opiate addiction, PLAN X should and must cover medication-assisted treatment that utilizes methadone. Excluding use of methadone from Affordable Care Act (ACA) coverage could violate several provisions of the ACA, including the parity, and non-discrimination provisions of the federal law. To be brought into compliance with the requirements of the law, PLAN X must be supplemented to cover medication-assisted treatment that utilizes methadone.
  • Medications are an essential tool to assist in the treatment of all chronic illnesses. There are only three federally approved medications to treat chronic opioid addiction. The rate of prescription drug misuse and heroin abuse is increasing nationally; SAMHSA estimates that X# of people (in STATE X, if data is available) need treatment for problems with illicit and prescription opiates. Excluding the use of methadone in treatment for opioid addiction from ACA coverage will severely restrict access to a treatment that is an approved standard of practice for opioid addiction.
  • Numerous studies recognize the effectiveness of methadone as a medication for maintenance, detoxification and medically supervised withdrawal. Methadone is a highly regulated medication, with extensive accreditation, licensing and other oversight requirements at both the federal and state levels. Methadone offers pharmacologic benefits that help to support an individual’s efforts to achieve and sustain abstinence, and is particularly effective for patients with long term histories of chronic opioid addiction who have a high narcotic tolerance. Methadone is also effective in helping individuals to stay in treatment. Research has also shown that methadone is a cost-effective medication.
  • Excluding coverage for treatment with methadone would violate the parity requirements of the ACA.
    • Excluding coverage for one of the three medications approved for the treatment of opioid addiction would violate the parity requirements of the ACA. PLAN X covers a number of medications to help in the treatment of other chronic illnesses including hypertension, cancer and heart disease. Allowing the methadone exclusion to remain in the plan would be the equivalent of the plan also excluding coverage for 1/3rd of the medications approved for the treatment of another chronic illness.
    • Methadone is a highly effective medication for individuals with opiate addiction. Medications are a critical piece of the continuum of care for all chronic illnesses. Excluding coverage for a medication that been an important part of the continuum of care for people with opioid addiction is contrary to established national standards of care and accordingly violates parity. Excluding methadone would disproportionately and harmfully restrict access to an effective treatment for certain individuals with opioid addiction. To be brought into compliance with the parity requirements of the ACA, PLAN X must be supplemented to cover treatment that utilizes methadone.
    • A review of PLAN X’s medical necessity criteria used to determine the exclusion of medication-assisted treatment that utilizes methadone is necessary to complete a full parity analysis. Stakeholders in STATE X need to have full access to the plan’s medical necessity criteria that was used to determine that use of methadone could be legally excluded. Under the parity requirements of the ACA, if the criteria used to determine which medications to assist in the treatment of SUD or mental illness should be covered is different from and/or applied more stringently than the criteria used to determine coverage for medications used to assist in the treatment of other illnesses, that would also represent a violation of the law.
  • Excluding use of methadone for the treatment of opioid addiction would be inconsistent with the non-discrimination requirements of the ACA. Allowing plans required to comply with the Essential Health Benefit (EHB) requirements of the ACT to exclude use of methadone from coverage is contradictory to the ACA’s requirement that the EHB addresses the healthcare needs of diverse segments of the population. If medication-assisted treatment utilizing methadone is excluded as a service, individuals with opiate addiction will have their choice of treatment severely restricted. Methadone is a highly effective medication that is consistent with recognized standards of clinical care and is beneficial to diverse groups of people whose health needs have traditionally not been well met. People with opioid addiction have been particularly stigmatized and have historically experienced considerable discrimination. Singling out for denial of coverage a specific medication which is essential for a significant number of people with a disability to become and stay well suggests the type of discrimination that is precluded by the ACA.
  • Excluding coverage for one of the three medications approved to help treat opioid addiction also is contrary to ensuring meaningful consumer choice in care, a central principle of the ACA. Methadone has a distinct pharmacological profile for which there is no adequate substitute for certain patient populations. Excluding coverage of the use of methadone to treat opioid addiction through the ACA would severely and unfairly restrict access to and consumer choice for an effective medication. The full range of medications approved for the treatment of MH and SUD should be covered by PLAN X.
  • Medications are an essential tool to assist in the treatment of all chronic illnesses. Consumers in STATE X should have good access to medications that are effective in the treatment of all illnesses, including mental illness and substance use disorders.
  • The drug formulary for PLAN X’s Qualified Health Plan (QHP) should include comprehensive coverage of each class of medications that are approved to assist in the treatment of mental illness and SUD. Not all patients respond to medicines in the same way. Physicians may need to change medications over the course of an illness as patients suffer side-effects or their illness is less responsive to a particular drug, and patients requiring multiple medications may need access to alternatives to avoid harmful interactions.
  • To ensure that individuals with MH and SUD have good access to effective medication, PLAN X’s QHP should offer coverage for all or substantially all FDA-approved prescription medications in each class, including the following classes of drugs to assist in the treatment of mental illness and SUD:
    • Antipsychotic medications
    • Antidepressant medications
    • Bipolar agents/Mood stabilizers
    • Anticonvulsant medications
    • Anti-anxiety medications
    • ADHD medications
    • Anti-Addiction/Substance Abuse Treatment Agents/Opioid medications
  • If PLAN X’s QHP fails to include comprehensive coverage of medications approved to assist in the treatment of mental illness and SUD, this would constitute a violation of the parity requirements of the ACA. The QHP covers a number of medications to help in the treatment of other chronic illnesses including hypertension, cancer and heart disease. If coverage of MH/SUD medications is significantly more limited than medications utilized in the treatment of other chronic illnesses, this would violate parity. Medications are a critical piece of the continuum of care for all chronic illnesses. Failing to provide comprehensive coverage of medications approved by the FDA to assist in the treatment of SUD or mental illness would be contrary to established national standards of care and accordingly violate parity.
  • A review of the QHP’s medical necessity criteria used to determine the exclusion of certain medications utilized in the treatment of mental illness/SUD is necessary to complete a full parity analysis. Stakeholders in STATE X need to have full access to the plan’s medical necessity criteria to determine if the base-benchmark coverage of MH/SUD medications complies with the consumer-protective requirements of the law. Under the parity requirements of the ACA, if the criteria used to determine which medications to assist in the treatment of SUD or mental illness should be covered is different from and/or applied more stringently than the criteria used to determine coverage for medications used to assist in the treatment of other illnesses, that would also represent a violation of the law.
  • Failing to provide good coverage of medications approved to assist in the treatment of mental illness or SUD would be inconsistent with the non-discrimination requirements of the ACA. Allowing QHP plans to exclude MH/SUD medications from coverage is contradictory to the ACA’s requirement that the Essential Health Benefits (EHB) address the healthcare needs of diverse segments of the population. If PLAN X’s QHP plan doesn’t include comprehensive coverage of MH/SUD medications, individuals with MH/SUD will have their choice of treatment severely restricted. There are many highly effective medications to assist in the treatment of mental illness and SUD that are consistent with recognized standards of clinical care and are beneficial to diverse groups of people whose health needs have traditionally not been well met.
  • Failing to provide comprehensive coverage of MH/SUD medications is also contrary to ensuring meaningful consumer choice in care, a central principle of the ACA. Excluding coverage of a significant number of medications approved to treat MH/SUD through the ACA would severely and unfairly restrict access to and consumer choice for an effective medication. The full range of medications approved for the treatment of MH and SUD should be covered in PLAN X’s QHP.
  • As a required essential health benefit (EHB) category, mental health and substance use disorder (MH and SUD) services must be covered in each Qualified Health Plan (QHP) operating on the health insurance exchange/marketplace. If a QHP fails to provide sufficient coverage of MH and SUD services, the plan must be supplemented to be brought into compliance with the EHB requirements of the Affordable Care Act (ACA).
  • Under the Mental Health Parity and Addiction Equity Act (MHPAEA) requirements of the ACA, access to MH and SUD services cannot be more restrictive than for other medical and surgical benefits covered by the plan. If the MH and SUD coverage in the QHP plan is more limited than for other illnesses, the coverage could violate the MHPAEA requirements of the ACA and would need to be supplemented.
  • QHPs should include coverage for the full continuum of MH and SUD care, ranging from lowest to highest levels of care for patients with mild to severe service needs. The medical establishment has long recognized and supported the need for a full continuum of evidence-based, effective care. The QHP includes coverage of the full continuum of services for other chronic illnesses, ranging from the least intensive to the most intensive in a variety of appropriate settings.   Patient placement tools will help to ensure that individuals are placed in the clinically appropriate level of care for the appropriate amount of time. Excluding coverage for a core service in the continuum of care will make it less likely that individuals will be placed in a clinically appropriate level of care and will increase the likelihood of negative clinical outcomes.
  • To be consistent with established standards of care and meet the ACA’s parity requirements, the full continuum of MH and SUD care must be covered in each QHP. Specifically:
    • The ACA requires coverage of a number of preventive MH/SUD services including alcohol and drug use screenings for children and assessments for adolescents, developmental screenings for infants and young children, early childhood autism screenings, developmental surveillance for all children, psychosocial/behavioral assessments for all children, alcohol misuse screening and counseling for adults, depression screening for adolescents and adults, and tobacco use counseling for adults and interventions for pregnant women. To comply with the ACA, QHPs must cover each of the previously listed MH and SUD preventive services.

INSERT SPECIFICS ACCORDING TO COVERAGE GAPS IN YOUR STATE’s PLAN:

  • Just as the QHP covers services to educate individuals about their illness and how best to manage their chronic disease, similar educational consumer guidance services about MH and SUD should also be covered.
  • The QHP covers chronic disease management and wellness services to help people with chronic illnesses become and stay well. Wellness services for MH and SUD, including recovery support services, should also be covered.
  • Just as the QHP provides coverage for medical and surgical services, with varying degrees of intensity, on both an outpatient and an inpatient basis and in a variety of appropriate settings, comparable levels of MH/SUD care should be provided in similarly licensed settings.
  • As a core component of the continuum of care for substance use disorders (SUD), residential SUD services should and must be covered in PLAN X’s health benefits (EHB) package. Excluding residential substance use disorder (SUD) treatment from Affordable Care Act (ACA) coverage violates several provisions of the ACA, including the parity and non-discrimination provisions of the federal law. To be brought into compliance with the requirements of the law, PLAN X must be supplemented to cover residential SUD treatment services.
  • Residential SUD treatment is an important, effective, evidence-based service in the continuum of care for people with SUD. SAMHSA (the Substance Abuse and Mental Health Services Administration) identifies residential SUD treatment as an important service in the SUD continuum of care. Residential SUD treatment has been identified as a critical part of the continuum of care in the American Society of Addiction Medicine (ASAM) Patient Placement Criteria. There are considerable existing national and state standards, requirements and accreditations for providers of residential SUD treatment services.
  • Residential SUD treatment services are provided in a non-hospital inpatient setting. Residential SUD treatment is characterized by a 24-hour deliberately structured therapeutic environment. The continuum of residential SUD treatment services corresponds with Level III of the ASAM Patient Placement Criteria. Levels of care in residential SUD treatment include medically monitored intensive inpatient, clinically managed 24-hour care, inpatient sub-acute, and short-term stabilization.
  • To comply with the ACA’s EHB and parity requirements, PLAN X should be supplemented to include coverage for the complete continuum of MH and SUD care, ranging from lowest to highest levels of care. The medical establishment has long understood and supported the need for a full continuum of evidence-based, effective care. The plan includes coverage of the full continuum of services for other chronic illnesses, ranging from the least intensive to the most intensive in a variety of appropriate regulated settings. The full continuum of MH and SUD care also must be covered. Comparable to the continuum for other chronic illnesses, the most intensive SUD services in the most structured environments are intended for individuals who cannot be effectively managed in less intensive levels of care. Patient placement tools will ensure that more intensive levels of care, such as residential SUD treatment, are reserved for only those individuals with the most severe needs for the appropriate amount of time. Excluding coverage for a core service in the continuum of care will make it less likely that individuals will be placed in a clinically appropriate level of care and will increase the likelihood of negative clinical outcomes. Individuals who are placed in less acute levels of care who need more structure and intensity of services will experience worse outcomes and will be more likely to need costly hospitalization or other avoidable healthcare services as a result of being denied access to the appropriate level of care for their needs.
  • Excluding coverage for residential SUD treatment could violate the parity requirements of the ACA.
    • Residential SUD treatment is identified by ASAM and other SUD experts (include specific mention of any medical bodies/clinical guidelines in STATE X) as a critical service in the continuum of substance use care. Excluding coverage for a service that is widely held to be an integral part of the continuum of care is contrary to established national standards of care and accordingly violates parity.
    • In addition, PLAN X’s exclusion of residential SUD treatment does not meet MH/SUD parity requirements since it fails to cover SUD services provided in a non-hospital inpatient setting while covering services for other chronic diseases that are provided in comparable non-hospital inpatient settings. Residential SUD treatment services have a similar degree of intensity to those provided in other non-hospital inpatient facilities for people recovering from other medical conditions. Under the plan, individuals who are determined to need care in a non-hospital inpatient facility for a chronic disease such as heart disease, stroke or diabetes would be covered. SUD services in a comparable non-hospital inpatient setting are excluded from coverage, severely restricting access to the clinically appropriate level and setting of care. This disparate coverage for SUD care violates the ACA parity requirements.
    • Plan documents suggest that the exclusion of residential SUD treatment would violate other parity requirements of the ACA.   To complete a more thorough parity analysis, stakeholders in STATE X need to examine the plan’s medical necessity criteria used to exclude residential SUD treatment and compare that with the criteria used to determine coverage for similar levels of care covered for other medical conditions. Under the parity requirements of the ACA, if the criteria used to determine which MH and SUD services should be covered in the base-benchmark is different from and/or applied more stringently than the criteria used to determine coverage for other medical/surgical benefits in the plan, the MH and SUD benefits in the plan would need to be supplemented to comply with the EHB’s parity requirement.
  • Excluding from coverage residential SUD treatment is contradictory to the ACA’s non-discrimination requirements that the EHB address the healthcare needs of diverse segments of the population. Residential SUD treatment services are clinically appropriate for certain individuals with serious substance use disorders. Failing to provide coverage for an essential level of care for people with the disease of addiction, while covering comparable levels of care for individuals with other illnesses, is discriminatory toward those ill, disabled individuals. Since the benefits offered in the plan exclude certain services and medications that are effective, consistent with recognized standards of clinical care, and are beneficial to diverse groups of people, including people with MH and SUD service needs, this coverage fails to meet the non-discrimination requirements of the ACA and needs to be supplemented.
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