Insurance coverage for the treatment of substance use disorders (SUDs)—which include the misuse of opioids, alcohol, and other drugs—varies dramatically among private and public insurers. While some payers cover the full spectrum of services recommended by evidence-based guidelines, others include arbitrary restrictions or omit coverage for services and medications approved for these diseases by the Food and Drug Administration. In fact, in 2015, nearly a third of Americans who felt they needed, but did not receive, treatment for an SUD cited lack of coverage as a reason.
The American Society of Addiction Medicine (ASAM) has established recommendations for effective SUD treatment based on disease severity. Seven services are incorporated in these guidelines, including inpatient and residential care, services to support long-term recovery, and access to the FDA-approved medications—methadone, buprenorphine, and naltrexone—for the treatment of opioid use disorder.
Unfortunately, many public and private payers fail to cover the evidence-based care identified by ASAM guidelines. For example, Medicaid coverage varies across states for medications and behavioral care. Only 13 Medicaid programs cover all seven services described in ASAM guidelines. Twenty-one states do not cover residential treatment, and only 32 programs cover methadone.
Even when Medicaid covers SUD treatment services, additional restrictions may apply that can prevent or delay access to evidence-based treatments. While these policies are allowable, their implementation varies across state programs. One such example is prior authorization, which is required for prescribing buprenorphine in 48 state Medicaid programs, but with significant differences in the process and documents needed for approval.
Similar barriers exist in private insurance, and some policies violate parity laws designed to ensure that coverage for SUD and mental health services are on a par with benefits for physical illnesses, such as heart disease or diabetes. In New York, Attorney General Eric Schneiderman brought lawsuits alleging that private insurers were imposing more restrictive limits on SUD services than on other medical and surgical benefits. Ultimately, insurers agreed to eliminate the restrictions and expand access to SUD treatment services.
Policymakers can work with both public and private insurance companies to ensure coverage of the full spectrum of lifesaving and cost-effective SUD treatment services.
Cynthia Reilly directs The Pew Charitable Trusts’ substance use prevention and treatment initiative; Samantha Arsenault works on the project.