Provide Access to Inpatient and Outpatient Care
After a SUD is diagnosed, ease of access to timely, high quality treatment is critical to initiate remission. Treatment of SUDs is a highly individualized process that often requires multiple treatment approaches. The inclusion of a variety of treatment modalities in the health plan can help improve the likelihood of members recovering.
Care for SUD can be carried out in a variety of settings and types of facilities, typically identified by types of treatment, length of stay, and intensity of treatment. It is important for members to be placed in the most appropriate level of care for their condition, situation, and goals as determined by the American Society of Addiction Medicine’s (ASAM) Levels of Care. A member’s level of care is determined by a provider after a diagnostic evaluation and comprehensive assessment. The assessment could be done by a primary care provider, mental health professional, or treatment facility covered by the health plan. There is no right course to moving between levels of care. To ensure members will have access to the treatment that they require, the heath plan should cover all levels of care.
Coverage limitations, cost-sharing requirements, and utilization management should be especially considered when designing benefits for inpatient and outpatient treatment. Employers should critically evaluate the financial and health-related impact that these components would have on their specific employee population based on income, location, and other social characteristics. Additionally, employers should require their health plans to examine network adequacy for treatment at the various levels of care and administration of evidence-based modalities.
Components of Care
The US Surgeon General recommends consideration of the following characteristics when looking for well-constructed treatment programs:
- Personalized diagnosis, assessment, and treatment planning
- Long-term disease management
- Access to FDA-approved medications
- Effective behavioral interventions delivered by trained professionals
- Coordinated care for co-occurring diseases and disorders
- Recovery support services
ASAM Levels of Care
There are 10 total levels of care, encompassed by four broader levels. Learn more here.
Provide Access to Behavioral and Mental Health Services
When compared with the general population, people with OUD are more likely to have a mental health disorder. Conversely, people with mental health disorders are more likely to have an OUD. An integrated approach to addressing these co-occurring conditions is important to fully supporting an individual’s recovery. For most people, a combination of medication and counseling is demonstrated to be the most effective method for promoting health and recovery. As with any chronic disease, treatment and recovery for behavioral health disorders are highly individualized processes. Necessary treatment methods, as well as their duration and frequency, can vary greatly among those affected.
Pain and psychological heath are also closely intertwined. An individual’s experience with pain can be strongly influenced by psychological factors, including its duration and severity, as well as the individual’s treatment adherence. The experience of pain can lead to increased psychological distress.
Employers should consider closely evaluating their behavioral and mental health offerings. Medical and mental health services should be adequately covered in accordance with the Mental Health Parity and Addiction Equity Act (MHPAEA). Network adequacy is important when evaluating coverage. In Kentucky, the integrated care needed to address co-occurring conditions is not widely adopted. Therefore, primary care providers who encounter patients with these conditions are challenged with assessing, referring, and managing patients’ behavioral health needs.
Mental Health Parity and Addiction Equity Act (MHPAEA)
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires the same approach to benefits for mental or SUD services that are available for medical/surgical care. The law does not require that health plans cover MH/SUD diagnoses, treatments, or services but rather requires health plans that do offer these benefits to do so equitably. The regulation applies to:
- Co-pays, coinsurance, and out-of-pocket maximums
- Limitations on service utilization
- Use of care management tools
- Coverage for out-of-network providers
- Criteria for medical necessity determination
Learn more here.