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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