People with low incomes in need of addiction treatment won a small victory at the end of March in the form of a newly issued federal rule aimed at ensuring greater fairness in the insurance market when it comes to treating addictions.
When the regulation takes effect May 31, it will be more difficult for many state Medicaid plans to limit the length of time someone with a substance use disorder can access the medications researchers have long agreed are critical to effective treatment.
Unfortunately, low-income people in Maine won’t share in that victory.
The new federal regulation is designed to ensure that health insurance plans cover treatments for mental health issues and addictions largely in the same way they cover treatments for medical and surgical problems. The regulation stems from the nearly eight-year-old Mental Health Parity and Addiction Equity Act signed into law by President George W. Bush.
While opiate addiction is a chronic disease, just as diabetes and arthritis are, insurance plans and state Medicaid programs often haven’t treated it as such. Case in point: The limited availability through Medicaid of the three medications approved by the FDA to treat opiate addictions and lifetime limits on their use.
A 2013 report published by the American Society of Addiction Medicine found that only 28 states’ Medicaid programs covered all three medications: methadone, buprenorphine (known commercially as Suboxone) and injectable naltrexone (sold as Vivitrol).
Fortunately, Maine is among those 28 states, but since 2013 the state generally has limited Medicaid recipients to two years on methadone and Suboxone. (Doctors can request special authorization from the state, so patients can continue their treatment.) Maine is one of 10 states, along with Washington, D.C., that impose a lifetime limit on Suboxone, according to a 2014 Substance Abuse and Mental Health Services Administration report.
Maine is the only state with a time limit on methadone out of the 33 whose Medicaid programs pay for methadone maintenance therapy, according to the SAMSHA report.
The lifetime limits on Suboxone and methadone are clear violations of the principles of parity and equity. No person with diabetes is subject to a two-year limit on insulin, after all, and no cancer patient is told that treatment coverage will simply stop after two years as a matter of policy.
As the SAMSHA report notes in its discussion of states’ lifetime limits on Suboxone: “This benefit design element is one that should be carefully considered by payers, because it can impose significant challenges for individuals with opioid use disorders. Opioid addiction is a chronic disease; as a result, individuals remain at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences.”
In other words, treatment for an opiate addiction rarely works within a neatly defined, two-year timeframe. Nevertheless, it has been legal for a state to impose lifetime limits on Medicaid coverage for methadone and Suboxone even as it imposes no such limits on other medications or treatments.
The newly issued federal regulation could prevent some of those Medicaid-imposed limits. If a Medicaid managed care organization — a privately managed organization a state contracts with to deliver Medicaid services and control costs — sought to impose a two-year limit on Suboxone, for example, it wouldn’t be allowed to unless it also imposed similar limits on other medications.
But Maine’s Medicaid program is exempt from the regulation.
The 2008 Mental Health Parity and Addiction Equity Act applies primarily to private insurers, including managed care organizations. And Maine is one of 12 states that doesn’t contract with managed care organizations for most Medicaid services. The parity requirements also extend to the plans offered to low-income residents who qualify for expanded Medicaid, but Maine has refused to expand Medicaid under the Affordable Care Act.
Maine’s two-year limits on methadone and Suboxone clearly go against the nature of addiction and inhibit effective treatment. It’s time for lawmakers to make lifting those limits a priority. And at the federal level, policymakers should do everything in their power to prevent states from following Maine’s path on addiction treatment.