Health insurance plans sold through the federal exchange system are showing a shocking lack of interest in complying with the Essential Health Benefits requirements laid down by the Patient Protection and Affordable Care Act as it applies to drug addiction treatment.

That’s the bottom line finding from an in-depth report from the National Center on Addiction and Substance Abuse.

The center studied state EHB benchmarks for plans with respect to coverage of addiction treatment methods. Every state benchmark falls far short of the mark on coverage elements.

The center identified rampant and outright violations of the PPACA, state policies that were so lax they did not promote effective addiction treatment and intervention, and lapses on the plan designers’ behalf that left huge holes in treatment coverage for addiction. The center says it couldn’t find a single plan that offered “adequate” EHB coverage, and notes two-thirds of them flat out violate the requirements of the reform law.

“Our findings reveal that people with addiction may not be receiving effective treatment because insurance plans aren't covering the full range of evidence-based care," says Lindsey Vuolo, JD, MPH, associate director of health law and policy at the National Center on Addiction and Substance Abuse, and lead author of the report. "For example, our review did not find a single state that covers all of the approved medications used to treat opioid addiction."

While the study — “Uncovering Coverage Gaps: A Review of Addiction Benefits in ACA Plans" — calls out insurers for failure to abide by the act’s requirements, it puts most of the blame at states’ doorsteps.

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The report from the National Center on Addiction and Substance Abuse that 60 percent of state plans fail to provide sufficient coverage for treating tobacco addiction. (Photo: iStock)

State action

States must establish an EHB benchmark that determines the specific addiction benefits to be included in plans sold in that state. That’s where the real trouble starts, the report says.

“The ACA does not identify which benefits should be covered; instead, each state chooses an EHB benchmark plan to determine which addiction benefits must be covered by the ACA plans sold in that state,” the authors say. And those benefits cited by most state benchmarks fall woefully short of addressing addiction. 

Specific findings included:

• Over two-thirds of the plans contain language that violates ACA requirements for addiction benefits.

• 18 percent of the plans do not comply with parity requirements.

• None of the plans provide comprehensive coverage for addiction by covering the full array of critical benefits without harmful treatment limitations.

• 88 percent of the plan documents lack sufficient detail to fully evaluate parity compliance and/or the adequacy of addiction benefits.

The report goes into great detail in describing the many gaps in addiction coverage created by the insufficient state benchmarks. For instance, it says that 60 percent of state plans fail to provide sufficient coverage for treating something as simple as tobacco addiction.

Worse, given the current heightened awareness about opioid abuse, it found that all of the state plans offered insufficient coverage for the drugs that are commonly used to address opioid addiction.

As the study notes, “Historically, insurance coverage for addiction has been insufficient. When people cannot access effective treatment, it can lead to disability, premature death, and a range of other costly health and social consequences. Conversely, effective treatment has been shown to not only save lives, but also reduce health care costs and decrease drug-related crimes.”

The PPACA sought to reverse this trend, and force insurers to treat addictions as diseases. But, according to this study, the states aren’t going along with the federal program.