Advocating for Addiction Treatment Care and Support for All
Addiction and mental health care should be readily accessible to everyone. Together, we’re working to end stigmas, increase empathy and prove that with the right access, recovery is possible.
The Call to Protect Life with Advocacy and Reform
While there are many valuable interests in the complex discussions over health care policy, none should take precedence over the highest duty we have to one another—protecting life.
As the nation's leading nonprofit provider of addiction prevention, treatment and recovery services, the Hazelden Betty Ford Foundation takes seriously our responsibility to help save lives, restore families and improve the social fabric of our communities and nation.
Drug and alcohol addiction is our nation’s most devastating public health crisis, affecting one in seven individuals and one in three families, while costing the economy $442 billion annually. Since 1999, more than a half million Americans have died from opioid and other drug overdoses. Alcohol kills even more. Yet today, while every $1 spent treating addiction saves $4 in other health care costs and $7 in criminal justice costs, only one in 10 individuals who need addiction treatment get it.
If protecting life is our highest priority, scaling back on insurance access and coverage for alcohol and drug addiction treatment is not an option, and the status quo is not enough. We need to strengthen and expand care and access to it, which means expanding health insurance coverage for addiction treatment and avoiding changes that might compromise that national priority.
Passage of legislation such as the Mental Health Parity and Addiction Equity Act in 2008, the Comprehensive Addiction and Recovery Act in 2016 and the 21st Century CURES Act in 2016 has demonstrated the bipartisan support for addressing the addiction crisis.
Those laws, together with other health care reforms, have established a new framework that, for the first time in our nation’s history, aims to address mental health and substance use disorders on par with physical illnesses. We have begun a historic shift to addressing the whole health of our citizens, and this new paradigm must be continued, strengthened and expanded.
Expanding Insurance Coverage for Substance Use Disorder Saves Lives
At the Hazelden Betty Ford Foundation, we have seen tremendous increases in health insurance utilization, which means more families are able to access the care they need.
It’s too often the case, however, that patients’ care is interrupted early due to insurance coverage limitations. And sometimes these patients are unable to re-engage in care when their symptoms return. That’s why we will continue to vigorously advocate for strong enforcement of the parity law.
We believe any reforms to the state and federal health care policy landscape should expand the ability of all Americans to access appropriate addiction treatment through their private or public health insurance plans.
Any other course will undoubtedly result in additional sickness, death, broken families, emergency room visits, hospital costs, criminal justice costs and child welfare costs.
We recognize the complex challenge policymakers face in pursuing both health care accessibility and health insurance affordability, and believe that any strategy to enhance America’s health systems clearly must prioritize coverage for addiction care.
As proposals are weighed and tough choices made in state capitals and Washington, we urge our elected officials to consider the pressing need and moral imperative to strengthen and expand life-saving coverage for addiction to alcohol and other drugs—and the economic opportunity in doing so.
Addiction is a bipartisan illness that demands a bipartisan solution, and we have been making bipartisan progress. We can and must continue to do so.
Addiction and Mental Health Parity Rights Explained
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.
The tools and resources provided here can help you understand your insurance plan and better access your insurance coverage for substance use disorder and mental health treatment.
Benefit Classification
Parity is determined on a classification basis. If an insurance plan offers medical/surgical benefits in one classification, it must also provide on-par mental health/addiction treatment (MH/SA) benefits in that classification. The six classifications are:
- Inpatient/in-network
- Inpatient/out-of-network
- Outpatient/in-network
- Outpatient/out-of-network
- Prescription drugs
- Emergency
Quantitative Parity Benefits
Quantitative benefits are those that can be measured easily. If an insurance company is not offering parity between quantitative benefits, it is usually easy to address. Some examples of quantitative benefits that are addressed by parity legislation are:
- Lifetime or annual dollar limits imposed on MH/SA benefits may NOT be more restrictive than those imposed on medical/surgical benefits.
- Financial requirements (e.g., deductibles, co-payments, coinsurance, out-of-pocket expenses) imposed on MH/SA benefits may NOT be more restrictive than those imposed on medical/surgical benefits.
- Treatment limitations (e.g., frequency of treatment, number of visits, number of days, or similar limits on scope or duration of treatment) imposed on MH/SA benefits may NOT be more restrictive than those imposed on medical/surgical benefits.
- There can be NO separate cost-sharing requirements or treatment limitations that are applicable only to MH/SA benefits.
Non-quantitative Treatment Limitations
There are limits on the scope or duration of mental health and substance use disorder treatment that are not so easily quantified. These non-quantitative treatment limits for MH/SA must be comparable to medical/surgical benefits:
- Medical management standards
- Use of fail-first or step therapy protocols
- Use of failure to complete a course of treatment
- Methods for determining usual, customary and reasonable charges
Additional Protections
There are a few additional protections offered through parity legislation.
Medical Necessity Determination and Disclosure
- Criteria for medical necessity determinations and the reason for any denial must be made available to contracted providers, or to the plan participant or beneficiary upon request.
- Plans can no longer take the position that medical necessity criteria or specific reasons for denial are "proprietary" or can otherwise be withheld. Please be sure to make your request is in writing, and seek a prompt/immediate response.
Where there is a state parity law or state mandate, the federal Mental Health Parity law serves as the floor and state laws must be enhanced to reach the federal floor.
Combined Deductibles and Out-of-Pocket Maximums
Deductibles and out-of-pocket maxes are to be combined for both medical/surgical and MH/SA benefits. (Annual and lifetime limits must be equal, but may be maintained separately). Be certain that plans are not quoting or applying separate deductibles or out-of-pocket maxes.
Advocacy Tools for Addiction and Mental Health Consumers, Providers and Advocates
Parity Toolkit
This comprehensive toolkit is designed to inform and assist you—as well as your family, care providers and recovery advocates—in accessing addiction treatment, and understanding your rights and benefits under the Mental Health Parity Act.
Use these materials to help you:
Communicate with your health insurance company about your plan coverage
Prepare and document information should disputes arise over coverage or reimbursement
Understand your rights to appeal as well as appeal procedures
Download the Addiction and Mental Health Parity Toolkit.
Insurance Coverage for Addiction and Mental Health: Now It Is the Law
This pamphlet will help you ask the right questions when working with your insurance company. It also provides a glossary to translate health insurance terms and language related to mental health and addiction treatment.
Download Now It Is the Law pamphlet.
Patient Request for Reasonable Denial
Use this letter template to request the reason for denial of addiction treatment coverage from your insurance company.
Download the Patient Reasonable Denial template.
Doctor/Provider Request for Reasonable Denial
This letter template may be completed by your doctor/provider to request the reason for denial of addiction care coverage from your insurance company.
Download the Doctor/Provider Reasonable Denial template.
Reforming “42 CFR Part 2” Privacy Regulations
Integrating specialized substance use disorder treatment services into the larger health care system requires that all health care providers communicate with each other seamlessly. Standing in the way, however, is an outdated rule known as 42 CFR Part 2 related to privacy and confidentiality of patient health information.
What is 42 CFR Part 2?
42 CFR Part 2 is a set of regulations put in place decades ago to ensure the privacy of patients who are treated for substance use disorders. Later, the Health Insurance Portability and Accountability Act (HIPAA) was enacted to protect the privacy of people receiving all kinds of health care services.
With HIPPA in place and working well to protect patient privacy and patient records, Part 2 is no longer needed. In fact, Part 2 actually serves as a barrier to accessing the best integrated care and deprives patients of the full benefits of modern health care services.
Why is it important to reform 42 Part 2?
Reforming the outdated regulations of Part 2 will increase access and improve care for patients who seek substance use treatment. This will enable providers to better coordinate the care of their patients and ensure all of a patient’s providers have the patient records and health information they need for safe, effective, high-quality treatment and care coordination in order to address all of a patient’s health needs on par with the broader health care system.
When screening, assessments, interventions, use of medications and care are coordinated between general health systems and specialty addiction treatment programs, both systems will benefit, improving quality, effectiveness and efficiency of care, and reducing costs.
That’s why we support bipartisan U.S. House of Representatives legislation to align the Part 2 requirements with those of HIPAA, which apply to all health care providers and allow the use and disclosure of patient health information when needed to facilitate optimal care. Patient privacy and confidentiality related to other diseases, including those that also carry significant stigma, are fully protected by HIPAA and state privacy statutes.
Part 2 currently limits patients’ rights to control their own health information and hinders access to electronic prescribing, electronic health record capabilities, treatment collaboration with other providers and processing of claims. The regulations are also unnecessarily burdensome on non-profit entities and those that treat the poor and elderly through government funds, as for-profit treatment providers are not subject to the Part 2 regulations.