The Issue

The Affordable Care Act contains requirements for health insurance plans to maintain sufficient networks of substance use disorder (SUD) and mental health (MH) service providers so that services are accessible without unreasonable delays. However, without strong enforcement and monitoring, it is likely that many plan enrollees will be unable to obtain the SUD and MH care they need.  Ongoing advocacy is needed to ensure that the provider network adequacy requirements are enforced.

Current Initiatives

  • Co-chairing and coordinating the Coalition for Whole Health to ensure the Affordable Care Act is well implemented for people with mental health and substance use disorder service needs.

Policy Recommendations

  • Strong network adequacy standards developed and enforced: Network adequacy standards that ensure timely access to SUD/MH benefits should be developed and enforced.  Specifically, the federal Department of Health and Human Services should provide guidance on:
    • Enrollee-to-provider and staff ratios, including ensuring a sufficient number of MH and SUD providers licensed or certified by the state are available to enrollees to ensure adequate choice, as well as a sufficient number of specialty providers to enrollees, as well as the ratio of enrollees to staff, including health professionals and administrative and other support staff;
    • Network sufficiency to ensure enrollees are able to access providers to address their MH and SUD needs within 24 hours for urgent care and within ten to fourteen calendar days for routine care, and to ensure that enrollees in need of more comprehensive, coordinated care are able to access providers that offer a full range of services;
    • Travel time and distance to providers, which should take into consideration geographical barriers and other barriers, such as a lack of accessibility by public transportation, that are not accounted for by simple mileage and travel time criteria;
    • Availability standards, including appointment waiting times, hours of operation, 24 hour service availability when medically necessary, and provider acceptance of new patients. Appointment standards should be followed for transitional care, preventive care, non-urgent care, and emergency care.

Learn More

To learn more about this issue, visit our Substance Use Resources.

To learn more about LAC’s impact, see our Accomplishments.

 

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