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Failure to Pay for Medication-Assisted Treatment

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at January 4, 2016

Happy New Year to all!

ModernHealthcare.com reporter Harris Meyer posted in his blog dated December 28, 2015 the article: “Is it smart to be stingy about covering addiction treatment?

In his post, he writes:

The conflict between health plans and providers over coverage of medication-assisted treatment for patients with opioid addiction highlights the ongoing tensions over government regulation of insurance benefit packages. And it raises questions about whether current benefit designs of private health plans are necessarily consistent with the broader public health goals.

Modern Healthcare’s Bob Herman reported last week that health insurance trade groups and provider groups are on opposite sides of a debate over whether the Obama administration should deem medication-assisted treatment (MAT) a mandated benefit under the Affordable Care Act’s essential benefits provision.

Many hospital associations, drug treatment centers, psychiatrists, primary-care physicians and individual patients recently sent the CMS written comments supporting full coverage of MAT…. But America’s Health Insurance Plans, the Blue Cross and Blue Shield Association, the Pharmaceutical Care Management Association, Express Scripts Holding Co., CVS Health Corp., and UnitedHealth Group sent the CMS written comments that they should not be required to pay for any specific treatment for opioid addiction. “We are concerned that by mandating specific benefits within an (essential health benefits) category, CMS may establish a precedent of imposing essential health benefit mandates in the future,” the Blues association wrote. That, it warned, could lead to premium increases. The insurance groups said they should be able to make their own coverage decisions for specific drugs.

This coverage debate is playing out at a time when the U.S. is facing what many experts consider a national opioid addiction crisis, with sharply rising numbers of Americans becoming addicted and dying from opioid overdoses. Nearly 29,000 people died in 2014 from overdoses of prescription painkillers, heroin and other opioids, according to the Centers for Disease Control and Prevention. Both Republican and Democratic politicians are calling for expanded treatment.

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