Greater than 100,000 folks died from drug overdoses in 2021 in keeping with CDC estimates, an almost 15 % improve from 2020. Round three-quarters of overdose deaths have been on account of opioids. Opioid-related deaths have risen precipitously during the last decade. But we know that medication-assisted remedy (MAT) is efficient at lowering the variety of deaths related to opioid use dysfunction (OUD). Pandemic-related insurance policies loosening federal necessities to fulfill with suppliers in particular person improved MAT entry, however these adjustments (together with different insurance policies to broaden well being care entry throughout the pandemic) are set to run out on the finish of the general public well being emergency (PHE). As well as, non-public medical insurance doesn’t at all times cowl the simplest OUD remedy medicines. Given the excessive dying toll of the opioid epidemic and the logistical complexities of accessing MAT, many policymakers are in search of methods to decrease insurance coverage boundaries to care.
OUD Sufferers Face Myriad Obstacles to Acquiring Medicine-assisted Remedy
Of the three medicines accredited by the FDA to deal with OUD, buprenorphine and methadone are recognized to be essentially the most efficient. As a result of each medicines are managed substances, and due to this fact topic to Drug Enforcement Company (DEA) restrictions, there are strict limitations on the place, when, and the way suppliers prescribe and sufferers acquire MAT. The geographic distribution of clinics and requirement to obtain the medicine in particular person a number of days per week additionally pose challenges to OUD sufferers’ MAT entry.
Even sufferers who can acquire a prescription and get to a clinic usually face obstacles paying for care. Protection of MAT varies throughout private and non-private payers—the Facilities for Medicare & Medicaid Providers (CMS) issued a rule in late 2020 requiring Medicaid to cowl methadone remedy in all fifty states and the District of Columbia (beforehand, a variety of state Medicaid packages didn’t cowl methadone), and Medicare has coated methadone as a medical profit since 2020. Nonetheless, non-public protection of methadone has been inconsistent, and a few insurers solely cowl one sort of medicine, limiting enrollees’ remedy choices. For plans supplied via the Inexpensive Care Act (ACA) marketplaces, enrollees have confronted uneven entry to each the accredited medicine and to the clinics that dispense them. In 2018, CMS discovered that “there may be not complete, nationwide protection of the medicine utilized in MAT” amongst market plans.
Along with gaps in protection, many OUD sufferers face prior authorization necessities and a lack of in-network suppliers, to not point out excessive value sharing—one report discovered that annual value sharing for OUD remedy averaged over $700 in 2018 plans, posing an insurmountable impediment to MAT for a lot of OUD sufferers who can not afford the excessive out-of-pocket prices for his or her remedy.
Federal Policymakers Have Taken Steps to Enhance MAT Protection
In gentle of those insurance-related obstacles to efficient OUD remedy, federal policymakers are taking motion to enhance entry to MAT. Longstanding federal legislation, the Psychological Well being Parity and Habit Fairness Act (MHPAEA), prevents insurers from imposing extra stringent limitations on substance use dysfunction advantages than medical/surgical advantages, together with value sharing and utilization administration strategies. However compliance and enforcement have been inconsistent; a 2022 report discovered that enrollees usually face an inadequate variety of in-network suppliers that deal with substance use dysfunction (SUD), suggesting gaps within the monitoring and analysis of parity necessities that apply to insurers’ network-building processes and requirements. The report additionally notes that carriers have interaction in “unequal remedy limitations, prior authorization necessities, and remedy exclusions,” impeding affected person entry to SUD providers. In response, federal policymakers are considering insurance policies to enhance parity oversight and enforcement.
A number of current federal legislative proposals intention to enhance parity enforcement. Members of Congress not too long ago re-introduced the Behavioral Well being Protection Transparency Act to require insurers—together with market insurers, group well being plans, and third-party directors—to yearly submit knowledge on non-quantitative remedy limits (NQTLs), comparable to prior authorization and psychological well being and SUD service claims denials to help in parity enforcement. This builds on the Consolidated Appropriations Act of 2021, which (amongst different issues) requires insurers to arrange comparative analyses of NQTLs imposed on psychological well being and SUD providers, and make these analyses accessible to state regulators. Moreover, President Biden’s proposed price range for 2023 consists of a number of provisions to extend entry to SUD providers, comparable to requiring all insurers, together with employer-sponsored well being plans, to cowl SUD remedy; investing within the Division of Labor’s capability to make sure employers’ compliance with substance use dysfunction protection necessities; funding state regulators’ parity enforcement efforts; and boosting federal regulation of supplier community requirements and supplier reimbursement.
Administrative actions have strengthened protection of OUD remedy. Not too long ago, CMS added SUD remedy facilities to the class of “different” Important Neighborhood Suppliers that insurers can contract with to fulfill market community adequacy necessities starting in 2023. The company additionally bolstered community adequacy requirements for behavioral well being suppliers, a class that features suppliers of SUD remedy. Stakeholders have requested CMS to mandate that market insurers cowl of all FDA-approved MAT medicines, however CMS has not adopted this coverage.
States Can Take Motion to Bridge Gaps in Federal Regulation
Present federal protections don’t guarantee entry to all MAT medicines, however states can implement insurance policies to enhance MAT protection for residents in state-regulated well being plans.
Guaranteeing Protection by Updating Important Well being Advantages
Psychological well being and SUD remedy is considered one of ten classes of Important Well being Advantages (EHBs) that the ACA mandates insurers cowl within the non-grandfathered particular person and small group markets. Underneath present federal rules, states choose benchmark plans that outline what psychological well being and SUD remedy providers insurers should cowl, inside statutory guardrails. Some state benchmark plans explicitly don’t cowl methadone, whereas others are unclear on the topic; one evaluate discovered that methadone upkeep remedy was some of the widespread dependancy remedy exclusions in benchmark plans, and described a common lack of transparency surrounding protection of MAT.
By utilizing the benchmark plan choice course of to broaden MAT protection, states can keep away from federal necessities to defray the premium prices of any new profit mandate that exceeds their EHB. In response to the opioid disaster, some states have up to date their benchmark plans in ways in which enhance entry to MAT. For instance, Illinois, Michigan, and Oregon have added language prohibiting carriers from organising boundaries to MAT prescribing, comparable to prior authorization.
Eradicating Protection-Associated Limitations to Care
Decreasing Price Sharing: For OUD sufferers, delayed or forgone care can carry life-threatening penalties. States can cut back or eradicate value sharing for MAT in state-regulated insurance policy in order that sufferers usually are not pressured to forgo or delay wanted care as a result of burden of out-of-pocket prices.
Limiting Prior Authorization: In response to the opioid epidemic, some new state legal guidelines have restricted prior authorization necessities for OUD remedy. Different state officers have used regulatory authority or their bully pulpit to extend entry. For instance, Pennsylvania reached an settlement with non-public insurers to take away all prior authorization necessities for MAT.
On common, over 200 folks died from opioid-related overdoses every single day in 2021. Regardless of promising developments in state and federal insurance policies, increasing entry to lifesaving remedy requires extra pressing motion from state and federal lawmakers and regulators. Along with protection mandates, policymakers can take motion to restrict or prohibit value sharing in addition to prior authorization and different utilization administration strategies that cut back remedy entry. Whereas OUD sufferers face myriad obstacles to efficient remedy, coverage choices may help chart a course to a confirmed methodology for lowering opioid mortality charges, and reducing insurance-related boundaries to MAT is vital to making sure entry to this lifesaving care.