Template Language:
Your State’s Base-Benchmark Plan Excludes Methadone for Opioid Addiction Treatment
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As a highly effective medication to assist in the treatment of opiate addiction, STATE
X’s essential health benefits (EHB) package should and must cover medication-assisted
treatment that utilizes methadone. Excluding use of methadone from Affordable Care
Act (ACA) coverage in STATE X violates several provisions of the ACA, including the
parity, and non-discrimination provisions of the federal law. To be brought into
compliance with the requirements of the law, STATE X’s base-benchmark plan must be
supplemented to cover medication-assisted treatment that utilizes methadone.
Medications are an essential tool to assist in the treatment of all chronic illnesses. There
are only three federally approved medications to treat chronic opioid addiction. The rate
of prescription drug misuse and heroin abuse is increasing nationally; SAMHSA
estimates that X# of people (in STATE X, if data is available) need treatment for
problems with illicit and prescription opiates. Excluding the use of methadone in
treatment for opioid addiction from ACA coverage will severely restrict access to a
treatment that is an approved standard of practice for opioid addiction.
Numerous studies recognize the effectiveness of methadone as a medication for
maintenance, detoxification and medically supervised withdrawal. Methadone is a highly
regulated medication, with extensive accreditation, licensing and other oversight
requirements at both the federal and state levels. Methadone offers pharmacologic
benefits that help to support an individual’s efforts to achieve and sustain abstinence, and
is particularly effective for patients with long term histories of chronic opioid addiction
who have a high narcotic tolerance. Methadone is also effective in helping individuals to
stay in treatment. Research has also shown that methadone is a cost-effective
medication.
Excluding coverage for treatment with methadone would violate the parity requirements
of the ACA.
o Excluding coverage for one of the three medications approved for the treatment of
opioid addiction would violate the parity requirements of the ACA. The basebenchmark plan covers a number of medications to help in the treatment of other
chronic illnesses including hypertension, cancer and heart disease. Allowing the
methadone exclusion to remain in STATE X’s EHB plan would be the equivalent
of the plan also excluding coverage for 1/3rd of the medications approved for the
treatment of another chronic illness.
o In addition, under the parity requirements of the ACA, a plan’s MH/SUD
coverage must meet standards of clinical practice. Methadone is a highly
effective medication for individuals with opiate addiction. Medications are a
critical piece of the continuum of care for all chronic illnesses. Excluding
coverage for a medication that been an important part of the continuum of care for
people with opioid addiction is contrary to established national standards of care
and accordingly violates parity. Excluding methadone would disproportionately
and harmfully restrict access to an effective treatment for certain individuals with
opioid addiction. To be brought into compliance with the parity requirements of
the ACA, the base-benchmark plan must be supplemented to cover treatment that
utilizes methadone.
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o If the base-benchmark in your state is a small group plan: As a small group plan,
STATE X’s base-benchmark has not had to comply with the federal parity law
and will very likely need to be supplemented to meet the parity requirements of
the EHB. A review of the base-benchmark plan’s medical necessity criteria used
to determine the exclusion of medication-assisted treatment that utilizes
methadone is necessary to complete a full parity analysis. Stakeholders in
STATE X need to have full access to the plan’s medical necessity criteria to
determine if treatment with methadone can be legally excluded from the EHB.
Under the parity requirements of the ACA, if the criteria used to determine which
medications to assist in the treatment of SUD or mental illness should be covered
is different from and/or applied more stringently than the criteria used to
determine coverage for medications used to assist in the treatment of other
illnesses, that would also represent a violation of the law.
o If the base-benchmark in your state is a large group plan: A review of the basebenchmark plan’s medical necessity criteria used to determine the exclusion of
medication-assisted treatment that utilizes methadone is necessary to complete a
full parity analysis. Stakeholders in STATE X need to have full access to the
plan’s medical necessity criteria that was used to determine that use of methadone
could be legally excluded. Under the parity requirements of the ACA, if the
criteria used to determine which medications to assist in the treatment of SUD or
mental illness should be covered is different from and/or applied more stringently
than the criteria used to determine coverage for medications used to assist in the
treatment of other illnesses, that would also represent a violation of the law.
Excluding use of methadone for the treatment of opioid addiction would be inconsistent
with the non-discrimination requirements of the ACA. Allowing EHB plans to exclude
use of methadone from coverage is contradictory to the ACA’s requirement that the EHB
addresses the healthcare needs of diverse segments of the population. If medicationassisted treatment utilizing methadone is excluded as a service, individuals with opiate
addiction will have their choice of treatment severely restricted. Methadone is a highly
effective medication that is consistent with recognized standards of clinical care and is
beneficial to diverse groups of people whose health needs have traditionally not been
well met. People with opioid addiction have been particularly stigmatized and have
historically experienced considerable discrimination. Singling out for denial of coverage
a specific medication which is essential for a significant number of people with a
disability to become and stay well suggests the type of discrimination that is precluded by
the ACA.
Excluding coverage for one of the three medications approved to help treat opioid
addiction also is contrary to ensuring meaningful consumer choice in care, a central
principle of the ACA. Methadone has a distinct pharmacological profile for which there
is no adequate substitute for certain patient populations. Excluding coverage of the use
of methadone to treat opioid addiction through the ACA would severely and unfairly
restrict access to and consumer choice for an effective medication. The full range of
medications approved for the treatment of MH and SUD should be covered in the EHBbenchmark plan.