Cover It: Insurance for Addiction Treatment
ASAM identifies and advocates for policies and practices that ensure equitable access to, and coverage for, comprehensive, high-quality addiction care for all.
In 2023, ASAM will continue to advocate for federal legislation and regulations that ensure equitable access to, and coverage for, comprehensive, high-quality addiction care for all. This means that benefit plans should be comprehensive and reflective of the complexity of the disease of addiction. In both public and private sectors, plans should cover the entire continuum of clinically effective and appropriate services provided by licensed and certified professionals, including all levels of care defined by The ASAM Criteria, and should provide coverage at parity with those benefits covering general medical illnesses, with the same provisions, lifetime benefits, and catastrophic coverage. Federal- or state-sponsored plans that provide coverage for persons who are otherwise uninsured must not exclude coverage for the diagnosis, prevention, treatment, and maintenance-of-remission of addiction. The “inmate exclusion” that bars the use of federal Medicaid matching funds from covering healthcare services in jails and prisons should be repealed and the inmate limitation on benefits under Medicare should be removed. Continuation of healthcare coverage during detention and incarceration will facilitate treatment continuity and retention.
Mental Health and Addiction Parity
In 2022, ASAM successfully advocated for the enactment of federal legislation extending mental health and addiction parity requirements to nonfederal governmental health plans, as set forth in Section 1321 of the Consolidated Appropriations Act, 2023. In addition, ASAM successfully advocated for authorization of new grants for state insurance departments so they can dedicate the staff time and resources necessary to meaningfully examine comparative analyses requested from insurers, as set forth in Section 1331 of the Consolidated Appropriations Act, 2023.
Amendments to the Medicaid Inmate Exclusion Policy
In 2022, ASAM successfully advocated for the enactment of federal legislation giving States the option to allow eligible juveniles to continue receiving Medicaid-funded health care while awaiting trial. This policy reform is set forth in Section 5122 of the Consolidated Appropriations Act, 2023.
Medicare OTP Bundled Payment
In the 2020 Medicare Physician Fee Schedule (MPFS), CMS finalized a methodology to implement the new Medicare Part B benefit for OUD treatment services furnished by OTPs that was established by the SUPPORT Act. Starting January 1, 2020, CMS pays OTPs through bundled payments for OUD treatment services in an episode of care provided to people with Medicare Part B. Read more.
Bundled Payments under the PFS for Substance Use Disorders (HCPCS codes G2086, G2087, and G2088)
In the CY 2020 PFS final rule (84 FR 62673), CMS finalized the creation of new coding and payment describing a bundled episode of care for the treatment of Opioid Use Disorder (OUD). In response to requests to expand those bundled payments to be inclusive of other SUDs, not just OUD, CMS revised the code descriptors by replacing “opioid use disorder” with “a substance use disorder.” The payment and billing rules otherwise remain unchanged. Read more.
Medicare OUD Demonstration
As a result of the SUPPORT Act, the Centers for Medicare & Medicaid Services (CMS) launched the Value in Opioid Use Disorder Treatment Demonstration, also known as the Value in Treatment Demonstration. Starting in April 2021, this 4-year demonstration tests whether a new care management fee and performance-based incentive for opioid use disorder (OUD) treatment services can cut hospitalizations and improve health outcomes for individuals with OUD. Read more.
ASAM and the American Medical Association (AMA) jointly released a conceptual alternative payment model entitled the "Patient-Centered Opioid Addiction Treatment (P-COAT) Alternative Payment Model." The model is designed to increase the utilization of office-based treatment of opioid use disorder by providing adequate financial support to successfully treat patients and broaden the coordinated delivery of medical, psychological, and social support services.
ASAM works with its state chapters and CMS to secure approval of section 1115 waivers to ensure appropriate funding and coverage of addiction treatment.
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