More than 100,000 people died from drug overdoses in 2021 according to CDC estimates, a nearly 15 percent increase from 2020. Around three-quarters of overdose deaths were due to opioids. Opioid-related deaths have risen precipitously over the last decade. Yet we know that medication-assisted treatment (MAT) is effective at reducing the number of deaths associated with opioid use disorder (OUD). Pandemic-related policies loosening federal requirements to meet with providers in person improved MAT access, but these changes (along with other policies to expand health care access during the pandemic) are set to expire at the end of the public health emergency (PHE). In addition, private health insurance does not always cover the most effective OUD treatment medications. Given the high death toll of the opioid epidemic and the logistical complexities of accessing MAT, many policymakers are seeking ways to lower insurance barriers to care.
OUD Patients Face Myriad Obstacles to Obtaining Medication-assisted Treatment
Of the three medications approved by the FDA to treat OUD, buprenorphine and methadone are known to be the most effective. Because both medications are controlled substances, and therefore subject to Drug Enforcement Agency (DEA) restrictions, there are strict limitations on where, when, and how providers prescribe and patients obtain MAT. The geographic distribution of clinics and requirement to receive the medication in person multiple days per week also pose challenges to OUD patients’ MAT access.
Even patients who can obtain a prescription and get to a clinic often face obstacles paying for care. Coverage of MAT varies across public and private payers—the Centers for Medicare & Medicaid Services (CMS) issued a rule in late 2020 requiring Medicaid to cover methadone treatment in all fifty states and the District of Columbia (previously, a number of state Medicaid programs did not cover methadone), and Medicare has covered methadone as a medical benefit since 2020. However, private coverage of methadone has been inconsistent, and some insurers only cover one type of medication, limiting enrollees’ treatment options. For plans offered through the Affordable Care Act (ACA) marketplaces, enrollees have faced uneven access to both the approved drugs and to the clinics that dispense them. In 2018, CMS found that “there is not comprehensive, nationwide coverage of the drugs used in MAT” among marketplace plans.
In addition to gaps in coverage, many OUD patients face prior authorization requirements and a lack of in-network providers, not to mention high cost sharing—one report found that annual cost sharing for OUD treatment averaged over $700 in 2018 plans, posing an insurmountable obstacle to MAT for many OUD patients who cannot afford the high out-of-pocket costs for their treatment.
Federal Policymakers Have Taken Steps to Improve MAT Coverage
In light of these insurance-related obstacles to effective OUD treatment, federal policymakers are taking action to improve access to MAT. Longstanding federal law, the Mental Health Parity and Addiction Equity Act (MHPAEA), prevents insurers from imposing more stringent limitations on substance use disorder benefits than medical/surgical benefits, including cost sharing and utilization management techniques. But compliance and enforcement have been inconsistent; a 2022 report found that enrollees often face an insufficient number of in-network providers that treat substance use disorder (SUD), suggesting gaps in the monitoring and evaluation of parity requirements that apply to insurers’ network-building processes and standards. The report also notes that carriers engage in “unequal treatment limitations, prior authorization requirements, and treatment exclusions,” impeding patient access to SUD services. In response, federal policymakers are contemplating policies to improve parity oversight and enforcement.
Several recent federal legislative proposals aim to improve parity enforcement. Members of Congress recently re-introduced the Behavioral Health Coverage Transparency Act to require insurers—including marketplace insurers, group health plans, and third-party administrators—to annually submit data on non-quantitative treatment limits (NQTLs), such as prior authorization and mental health and SUD service claims denials to aid in parity enforcement. This builds on the Consolidated Appropriations Act of 2021, which (among other things) requires insurers to prepare comparative analyses of NQTLs imposed on mental health and SUD services, and make these analyses available to state regulators. Additionally, President Biden’s proposed budget for 2023 includes several provisions to increase access to SUD services, such as requiring all insurers, including employer-sponsored health plans, to cover SUD treatment; investing in the Department of Labor’s capacity to ensure employers’ compliance with substance use disorder coverage requirements; funding state regulators’ parity enforcement efforts; and boosting federal regulation of provider network standards and provider reimbursement.
Administrative actions have strengthened coverage of OUD treatment. Recently, CMS added SUD treatment centers to the category of “other” Essential Community Providers that insurers can contract with to satisfy marketplace network adequacy requirements beginning in 2023. The agency also bolstered network adequacy standards for behavioral health providers, a category that includes providers of SUD treatment. Stakeholders have asked CMS to mandate that marketplace insurers cover of all FDA-approved MAT medications, but CMS has not adopted this policy.
States Can Take Action to Bridge Gaps in Federal Law
Current federal protections do not ensure access to all MAT medications, but states can implement policies to improve MAT coverage for residents in state-regulated health plans.
Ensuring Coverage by Updating Essential Health Benefits
Mental health and SUD treatment is one of ten categories of Essential Health Benefits (EHBs) that the ACA mandates insurers cover in the non-grandfathered individual and small group markets. Under current federal regulations, states select benchmark plans that define what mental health and SUD treatment services insurers must cover, within statutory guardrails. Some state benchmark plans explicitly do not cover methadone, while others are unclear on the subject; one review found that methadone maintenance therapy was one of the most common addiction treatment exclusions in benchmark plans, and described a general lack of transparency surrounding coverage of MAT.
By using the benchmark plan selection process to expand MAT coverage, states can avoid federal requirements to defray the premium costs of any new benefit mandate that exceeds their EHB. In response to the opioid crisis, some states have updated their benchmark plans in ways that improve access to MAT. For example, Illinois, Michigan, and Oregon have added language prohibiting carriers from setting up barriers to MAT prescribing, such as prior authorization.
Removing Coverage-Related Barriers to Care
Lowering Cost Sharing: For OUD patients, delayed or forgone care can carry life-threatening consequences. States can reduce or eliminate cost sharing for MAT in state-regulated insurance plans so that patients are not forced to forgo or delay needed care due to the burden of out-of-pocket costs.
Limiting Prior Authorization: In response to the opioid epidemic, some new state laws have limited prior authorization requirements for OUD treatment. Other state officials have used regulatory authority or their bully pulpit to increase access. For example, Pennsylvania reached an agreement with private insurers to remove all prior authorization requirements for MAT.
On average, over 200 people died from opioid-related overdoses every day in 2021. Despite promising developments in state and federal policies, expanding access to lifesaving treatment requires more urgent action from state and federal lawmakers and regulators. In addition to coverage mandates, policymakers can take action to limit or prohibit cost sharing as well as prior authorization and other utilization management techniques that reduce treatment access. While OUD patients face myriad obstacles to effective treatment, policy decisions can help chart a course to a proven method for reducing opioid mortality rates, and lowering insurance-related barriers to MAT is key to ensuring access to this lifesaving care.