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Leveraging the Equity Act and ACA To Improve Access to Addiction Treatment

Leveraging the Equity Act and ACA To Improve Access to Addiction Treatment. University of Arkansas at Little Rock February 28, 2014. Preview. Treatment Need Equity Act Affordable Care Act Restrictions on treatment Enforcing the Equity Act Conclusion. Treatment Need.

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Leveraging the Equity Act and ACA To Improve Access to Addiction Treatment

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  1. Leveraging the Equity Act and ACA To Improve Access to Addiction Treatment University of Arkansas at Little Rock February 28, 2014

  2. Preview • Treatment Need • Equity Act • Affordable Care Act • Restrictions on treatment • Enforcing the Equity Act • Conclusion

  3. Treatment Need • Prescription drug abuse epidemic • Synthetics, analogs, 3D printing • Marijuana legalization • 21.6 million Americans with SUDs • 89.6 percent untreated • 38,329 overdose deaths in 2010 • Stigma • Social • Structural

  4. Equity Act • Mental Health Parity and Addiction Equity Act of 2008 • Amends ERISA, PHSA, IRC • Financial requirements and treatment limits on MH/SUD benefits must be no more restrictive than those applicable to medical/surgical benefits • Group plans only (not small e’or or individual) • CMS, IRS, DOL announced Final Rule in Nov. 2013, effective Jan. 2014

  5. Affordable Care Act • Patient Protection and Affordable Care Act • Intended to expand coverage to six million people with SUDs by 2016 • Requires coverage of Essential Health Benefits (EHBs) • Small groups • Individuals • Exchanges • Medicaid ABPs • Mental health, SUDs included as EHBs

  6. ACA Expands Parity • ACA directs HHS to ensure balance among EHBs • HHS determined compliance requires applicability of Equity Act standards • Expands parity • (Previously just group plans voluntarily offering MH/SUD coverage) • Small groups • Individuals • Exchanges • Medicaid (with nuances)

  7. Medicaid Nuances • Equity Act Final Rules created misconception that regs do not apply to Medicaid plans • CMS guidance adopts framework of Equity Act • Medicaid ABPs must comply with Equity Act parity provisions • MCOs must comply with contracts with CMS • CMS guidance set forth specific parity standards applicable to MCOs

  8. Restrictions on Treatment • Certain services never medically necessary • Benefit not required under Equity Act • Harsh prior authorization and fail-first requirements (failure can mean overdose death) • Drastic cuts to reimbursement rates • Weakening baseline medical/surgical coverage • Lifetime limits on maintenance medications

  9. Enforcing the Equity Act • Complaints to state insurance departments (HHS/CMS as a backstop), appeals in state courts • Breach of K claims (Ks state insurers will comply w/ federal/state law) • Medicaid state hearings, class actions • Complaints to DOL (action on 0/160 complaints) • ERISA • Recover benefits due • Enforce rights • Clarify rights • Excise tax + IRS whistleblower

  10. Conclusion • Michael C. Barnes & Stacey L. Sklaver, Active Verification and Vigilance: A Method To Avoid Civil and Criminal Liability When Prescribing Controlled Substances, DePaul J. Health Care L. (2013). • Michael C. Barnes & Gretchen Arndt, The Best of Both Worlds: Applying Federal Commerce and State Police Powers To Reduce Prescription Drug Abuse. Md. J. Health Care L. & Pol’y (2013). • Twitter: @mcbtweets, @dcbalaw • LinkedIn.com/in/michaelcbarnes • Questions? • Thank you

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