David E. Williams

How to Cover Substance Abuse Treatment in Your Company’s Plan

The Affordable Care Act (ACA) has ushered in major shifts regarding how health insurance works and what it covers. Some of the most profound changes have been in coverage for substance abuse treatment.

Historically, mental health and substance abuse were viewed as “second-class syndromes.” That would sometimes include, for example, limiting the number of reimbursed visits, enforcing strict prior authorization protocols, offering narrow networks of providers and the capping of both annual and lifetime benefits. Such benefit designs compared unfavorably with the much more open nature of traditional medical benefits. When addiction treatment was covered, it was typically considered an existing condition where benefits could only be accessed after a waiting period. Now, the approach has changed.

Why This Coverage Is Important

The movement toward mental health parity preceded the passage of the ACA. The 1996 Mental Health Parity Act (MHPA) barred group health plans from making annual and lifetime benefit caps more restrictive for mental health than for the plan as a whole. The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) progressed further, by requiring comparable benefits and financial requirements for medical and surgical as well as mental health and substance abuse treatment. Progress on implementation was uneven, however, and parity wasn’t always achieved.

The ACA built upon the foundation of MHPA and MHPAEA. Mental health and substance abuse coverage is included in the list of 10 essential health benefits required of all small group and individual plans, according to the U.S. Centers for Medicare & Medicaid Services — putting it on par with benefits such as ambulatory services, hospitalization and prescription drugs. Coverage includes evaluation, treatment medication, drug testing, home health visits, family counseling and inpatient treatment. The ACA also eliminated annual and lifetime benefit caps and forbade exclusions for preexisting conditions.

A Rising Epidemic

Passage of the MHPAEA and ACA coincided with the onset of the opioid epidemic, which has been largely attributed to the rise of opioid prescribing. As the U.S. Department of Health & Human Services notes, 44 people die from a prescription drug overdose in this country every day. More people in the U.S. now die from drug overdoses than from car crashes or firearms, according to the Media Research Center. Many individuals who received prescription painkillers for dental surgery, lower back pain and other common conditions have become addicted. Extra pills left lying around in the medicine cabinet are a tempting target for abuse and have contributed to problems for many people, even teenagers. Shockingly, heroin use is running rampant across the country as addicts turn to street drugs when their prescription painkillers are cut off.

As a recent FAIR Health white paper explains, “Unlike earlier opioid abuse epidemics, the present crisis is disproportionately affecting white, middle-class people in non-urban settings, including those with private health insurance.” The impact on the insured population is truly staggering. From 2007 to 2014, commercial insurance claims for opioid dependence increased by 3,203 percent. The number of claims for drug dependence during pregnancy rose by 511 percent over the same time period.

What You Can Do for Your Employees

Because of this epidemic, you have an important role to play in educating employees about substance abuse benefits — but there are hurdles to surmount. Despite recent progress in the understanding of addiction and growing acceptance, people with substance abuse disorders are still stigmatized and blamed for their problems. With few exceptions, people want to keep their addiction private. That means they won’t ask human resources managers or co-workers about available coverage and treatments the same way they would when managing more socially acceptable conditions. Dependents are disproportionately affected by addiction, so you should emphasize the importance of mental health treatment for children and spouses.

There’s no silver bullet for connecting employees with addiction benefits. But a good place to start is by normalizing the discussion of substance abuse in the workplace and by making plenty of information available online, where no potentially uncomfortable interaction is needed. In keeping with its classification as an essential benefit, substance abuse coverage should be portrayed as a regular part of contemporary health insurance. Mention it when going over benefits with new hires or re-educating your team on their available coverage.

The incidence of addiction has risen sharply in recent years, and therefore, there’s a strong business and public health argument to publicize addiction diagnosis and treatment as part of your organization’s overall corporate wellness program. Confidentiality and discretion are paramount in dealing with these topics, so your employees must be assured their communications with HR and care providers will be treated as private. You can also leverage helpful resources that are offered by health plans, benefits consultants and third-party vendors, regarding how to best navigate the treatment and reimbursement environment.

This content is provided solely for informational purposes. It is not intended as and does not constitute legal advice. The information contained herein should not be relied upon or used as a substitute for consultation with legal, accounting, tax and/or other professional advisers.

David E. Williams is president of Health Business Group, a strategy consulting firm serving clients in technology-enabled health care services, pharmaceuticals, biotech, medical devices and software. He is frequently quoted in the media on the business of health care and is the author of the Health Business Blog. David sits on the board of both private health care companies and nonprofits.