addiction involving alcohol, and outpatient
hospital services involving detoxification,
rehabilitation and treatment for addiction
involving drugs other than nicotine;^149 Clinic-based treatment services for addiction
involving alcohol and detoxification services
for addiction involving opioids, under
physician supervision;^150 and
Tobacco cessation counseling from a
qualified physician or practitioner for all
smokers* and tobacco cessation medications
prescribed by a physician.^151
Methadone maintenance therapy also is covered
on an outpatient basis, but only when indicated
for pain, and in hospitals for treatment of
addiction involving opioids.^152
Differences in copayments for outpatient
addiction treatment and other outpatient services
will be phased out by 2014.^153
Private Health Insurers. Historically, private
health insurers have provided less coverage for
the treatment of addiction than for other health
conditions by setting lower annual or lifetime
limits on benefits,† covering fewer inpatient days
or outpatient visits and increasing cost sharing
through higher deductibles and copayments.^154
A survey of private health plans found that,
while only 16 percent of private insurance
offerings imposed lifetime limits on addiction
treatment, 94 percent had annual limits for
outpatient services and 89 percent had annual
limits for inpatient services. Private insurance
offerings were more likely to limit visits
(outpatient) or days (inpatient) than to limit
spending.^155
- Medicare covers two individual cessation
counseling attempts per year, and each attempt may
include up to four sessions.
† Annual limits are caps that insurers place on the
benefits an enrollee is entitled to each year. Limits
can apply to particular services (e.g.,
hospitalizations), number of visits or dollar amount
of covered services. Lifetime limits are caps on
expenditures, on specific services or both during an
individual’s lifetime.
Children’s Health Insurance Program (CHIP).
Under CHIP, formerly the State Children's
Health Insurance Program (SCHIP), states are
entitled to federal matching funds up to specified
limits to finance health care for low-income
children‡ who do not qualify for Medicaid.^156
States can provide benefits related to substance
use and addiction under CHIP by expanding
children’s eligibility under Medicaid, by
creating a separate insurance program or through
some combination of these approaches. States
that opt simply to expand their Medicaid
programs are required to follow the rules and
requirements of Medicaid.^157 States that provide
benefits by creating unique CHIP programs
(outside of Medicaid) must provide a benefits
package equivalent to one of several
“benchmark” insurance plans.§ 158 States have
latitude in designing their CHIP program.^159 A
2000 study found that almost all states provided
at least one of detoxification, inpatient/
residential or outpatient services, though many
states imposed annual limits (e.g., 20 or 60 visits
per year) or lifetime benefit limits (e.g., $16,000
or $20,000).^160Gaps in Addiction Care Coverage Within
Parity and Health Reform Initiatives. With
regard to federal parity laws, MHPAEA includes
an exemption if the financial burden of
implementing the law is too great,** 161 and small
employers (with less than 50 employees) are
exempt from the law completely.^162 Under
MHPAEA, insurance plans may cap services‡ Through waivers, states may expand CHIP
eligibility to pregnant women, low-income parents
and adults without children.
§ Such as the Blue Cross/Blue Shield Standard
Option Service Benefit Plan offered under the
Federal Employees Health Benefits Program
(FEHBP), a plan that is available to the state’s
employees or a plan offered by the HMO with the
largest enrollment in the state outside of Medicaid.
States also may use a benefits package that is
actuarially equivalent to one of the benchmark plans,
an already existing state-funded plan or any other
plan approved by the federal government.
** Health plans are exempt if complying with the law
results in a cost increase of greater than two percent
in the first plan year and greater than one percent in
subsequent years.