Ensure Equitable Access and Coverage for Comprehensive High-Quality Addiction Care

Access to care

Even where high-quality addiction treatment services are available, third-party payer policies that limit coverage or payments can prevent patients from accessing them. Narrow networks, onerous utilization management policies, and high cost-sharing requirements are just a few of the hurdles that patients may face when attempting to access treatment. 

All health benefit plans should include comprehensive coverage of evidence-based addiction treatment services. Plans should also provide coverage and payment at parity with general medical/surgical benefits, with the same provisions, lifetime benefits, and catastrophic coverage. Moreover, insurance benefit design should encourage coordinated and simultaneous treatment of co-occurring disorders. Thus, when a patient presents with addiction and any co-morbidity, integrated care should be covered whenever indicated. 

Recent Advocacy Successes:

  • In 2018, ASAM advocated for, and Congress enacted, legislation creating an OUD outpatient treatment demonstration program in Medicare — to be implemented in January 2021 — that emphasizes care coordination and the bio-psycho-social model of care. It also enhances reimbursement and focuses on accountability metrics. 
  • In 2018, ASAM advocated for, and Congress enacted, legislation providing for Medicare coverage of opioid treatment programs (OTPs) beginning January 2020.

Priorities Moving Forward

  • Federal legislation that gives the Department of Labor (DOL) additional enforcement authority to address ongoing violations of the Mental Health Parity and Addiction Equity Act (MHPAEA). 
  • Federal legislation that encourages recipients of federal grant funding for the delivery of addiction treatment services that are available pursuant to the applicable state's Medicaid Plan (or a waiver of such plan) to become Medicaid providers to better integrate federal grant dollars and Medicaid funds with the goal of increasing access to more comprehensive, high-quality care. 
  • Federal legislation that reduces the burden of utilization management policies, including prior authorization, on FDA-approved medications for addiction treatment and concurrent counseling and behavioral therapies. 
  • Federal legislation that increases Medicaid fees for addiction treatment services to at least Medicare levels. 
  • Federal legislation that repeals the “inmate exclusion” that bars the use of federal Medicaid matching funds from covering healthcare services in jails and prisons and removes the inmate limitation on benefits under Medicare.