ACA Marketplace Plans Could Potentially Block Treatment for Substance-Use Disorders


Cost-sharing and prior authorization could potentially prevent patients from receiving alcohol or opioid abuse treatment.

Patients with health insurance through Affordable Care Act marketplaces have good coverage for alcohol and opioid use disorders, but cost transparency could potentially prevent treatment barriers, a recent analysis revealed.

Researchers analyzed coverage and cost-sharing for medication-assisted treatment (MAT), inpatient and outpatient treatment for patients with substance-use disorders (SUD) in 6 major US cities, according to the study published by the Urban Institute. The cities included were Los Angeles, Chicago, Kansas City, Manchester, Albuquerque, and Memphis.

There are currently 3 approved medications for alcohol addiction and 3 approved for opioid addiction. However, the coverage and cost-sharing for these medications varies among plans in the different cities.

Researchers selected the 6 cities based on geographic dispersion, varying population size, and benchmark plan generosity.

The researchers defined benchmark plan generosity as the amount of medications essential health benefit (EHB) benchmark plans require insurers to cover. By law, health plans purchased from marketplaces must include coverage for SUDs.

They included data from and from each insurer’s web site for silver plans, in addition to inpatient and outpatient costs for these plans. Researchers found that the FDA-approved medications to treat alcohol use are more likely to be covered, compared with opioid treatments.

Approximately 70% of the plans had alcohol use MATs in the lowest cost-sharing tier. It was found that opioid treatments are less likely to be covered, but if they are covered, it is in the lower cost-sharing tiers.

Naltrexone, a drug used to treat opioid use and alcohol use, was excluded from 6% of plans for alcohol use, and was excluded from 29% of plans for opioid use. Investigators found that the drugs studied were likely to be covered under tier 1 or tier 2, but the cost-sharing varied in some places, according to the study.

Researchers also discovered approximately 42% of plans needed authorization for patients to receive treatment with buprenorphine for opioid use. Quantity limits are also in place for 66% of plans.

A majority of the plans also required prior authorization for inpatient services. However, they found that inpatient and outpatient care varied by city, as well.

In Albuquerque, 88% of silver plans required authorization for SUD inpatient services, while 40% of plans in Manchester had those requirements. Researchers believe that prior authorization could potentially be a barrier for patients seeking inpatient services, since these patients could potentially relapse or overdose without care.

It was found that outpatient services were typically less restricted compared with inpatient services.

The out-of-pocket maximums ranged from $3500 to $6850 for these plans, and the co-payments ranged from $250 to $2500, the researchers noted. These copayments were found to be more common for outpatient services compared with inpatient services.

In Chicago, copayments ranged from $10 to $75 per outpatient appointment, which the researchers stated was the largest range. Coinsurance ranged from 15% to 50% for some outpatient services.

Researchers noted a large variation in both inpatient and outpatient cost-sharing. Coinsurance is more common for inpatient care, while copayments were more common for outpatient services.

The study concluded that a variety of medications, inpatient, and outpatient treatments are available for patients with SUDs, but cost-sharing and prior authorization could potentially affect the care received or cause a treatment delay due to financial burden. Patients who are seeking treatment for SUDs must carefully assess the formularies and cost-sharing requirements for the plans in their area prior to choosing a plan to ensure they receive effective treatment.

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