Is substance abuse coverage as equal as required?

(USA TODAY) -- Insurance plans that cover substance abuse treatment must provide the same level of care and cost sharing as they do for other medical issues, but treatment centers say disagreement over what this means leaves many alcoholics and drug addicts without the coverage they need.

The Mental Health Parity and Addiction Equity Act of 2008 required comparable cost sharing and treatment for major medical needs and mental health and substance abuse when employer-provided insurance included these benefits - and most large company plans do.

As of Jan. 1, the Affordable Care Act then added mental health and substance abuse treatment to its list of essential health benefits that have to be covered in all individual and small business plans. And it can't be any more restrictive than medical coverage. Final rules dictating how this works came out in November.

"Many providers ... report less days and more difficulty with reimbursement since the final rules were established," says Michael Walsh, CEO of the National Association of Addiction Treatment Professionals. Many providers and insurers disagree "as to what the practical implementation of the rules should be and what should be covered."

An ongoing NAATP survey of treatment centers shows disputes over what qualifies as a "medical necessity" is behind 63% of denials for treatment coverage since last July. Twenty centers submitted details of 800 cases involving disputes over parity for the survey.

Insurers are often being tougher on what they'll allow than they were before the new rules, says Ben Brafman, CEO of Destination Hope treatment center in Fort Lauderdale. Addicts or alcoholics who the center's psychiatrist or licensed addictions professionals say need at least 30 days of in-patient treatment are now often getting up to five days approved and the center has to fight for every additional couple of days, he says.

Susan Pisano, a spokeswoman for the industry trade group America's Health Insurance Plans, acknowledges that there are "certainly demands placed on health insurers" under the ACA, but she says insurers "are still fully committed, and have always been, to quality of care."

The National Institute on Drug Abuse's principles of drug addiction treatment say "no single treatment is effective for everyone," Pisano points out. The document also notes research shows most patients need at least three months in treatment, but Pisano says that could be in- or out-patient.

"There's a lot of confusion within the industry on how health care reform is going to be enforced," says Nate Kasper, a Kansas treatment facility executive who is heading the NAATP study.

A recovering addict living with another addict doesn't have a safe environment to go home to and may need 90 days to a year of treatment, says Kasper. And some of the young opiate addicts his centers treat often relapse and overdose as soon as they finish short stints of detox.

Diane Schiraldi, a recovering alcoholic whose Aetna plan paid for 45 days at Destination Hope, says nothing would have changed with her drinking after a week or less in treatment.


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