Transcript ualr.edu
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
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
•
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
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
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)
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
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
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
Conclusion
Michael C. Barnes & Stacey L. Sklaver, Active Verification and
(2013).
Michael C. Barnes & Gretchen Arndt, The Best of Both Worlds:
Vigilance: A Method To Avoid Civil and Criminal Liability When
Prescribing Controlled Substances, DEPAUL J. HEALTH CARE L.
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