State Benchmark Plan Coverage of Opioid Use Disorder Treatments and Services: Trends and Limitations
By
By
Stacey A. Tovino[1]*
Legislation, regulation, scholarship, and journalism addressing the opioid crisis have focused on a number of front-end management strategies, including opioid production quotas,[2] opioid taxes,[3] drug labeling,[4] risk evaluation and mitigation strategies,[5] marketing restrictions,[6] physician prescribing practices,[7] prescription drug monitoring programs,[8] prescription safety alert systems,[9] maximum initial opioid prescription quantities,[10] continuing opioid education for opioid prescribers,[11] and temporary restraining orders for improper opioid prescribers.[12] Back-end crisis-management strategies, including needle exchange programs,[13] safe injection sites,[14] opioid reversal agent availability,[15] medication-assisted treatment,[16] mobile health care services,[17] mobile application-mediated prescription cognitive behavioral therapy tools,[18] national recovery housing best practices,[19] integrated treatment for individuals with concurrent mental disorders,[20] information sharing with families and caregivers during opioid overdoses,[21] and even sharply-written letters by medical examiners to prescribing physicians following a patient’s death due to overdose[22] have also received significant attention. Less attention has been paid, however, to state benchmark health plan coverage of opioid use disorder treatments and services.
This Article helps to fill this gap by surveying state benchmark plan coverage of opioid use disorder treatments and services and by identifying trends and limitations relevant thereto. This Article proceeds as follows: Part II provides background information regarding opioid use disorder and the treatments and services available for individuals with this disorder.[23] Part III reviews federal mental health parity law and federal mandatory mental health and substance use disorder law as applied to insurance coverage of treatments and services for opioid use disorder, with a focus on the Affordable Care Act’s (ACA’s) state benchmark health plan selection requirement and the effect on that requirement of a recent federal district court opinion striking down the ACA.[24] Appendix A documents state benchmark plan limitations potentially applicable to individuals with opioid use disorder,[25] and Part IV analyzes these trends.[26] A conclusion clarifies how the invalidation of the entire ACA could affect insurance coverage of opioid use disorder treatments and services going forward.[27]
“Opioids include [both] prescription analgesics as well as [the] products of the poppy plant [(Papaver somniferum)], including opium, morphine, and codeine.”[28] Although physicians prescribe opioids to relieve conditions and symptoms such as pain, cough, and diarrhea, opioids can also produce feelings of euphoria and tranquility that may lead some individuals to continue taking them, notwithstanding health risks associated with opioid use and abuse.[29] In the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA) defines opioid use disorder as the:
[P]roblematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following [criteria], occurring within a twelve month period: (1) Opioids are often taken in larger amounts or over a longer period of time than intended; (2) There is a persistent desire or unsuccessful efforts to cut down or control opioid use; (3) A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects; (4) Craving, or a strong desire to use opioids; (5) Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home; (6) Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids; (7) Important social, occupational or recreational activities are given up or reduced because of opioid use; (8) Recurrent opioid use in situations in which it is physically hazardous; (9) Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids; (10) Tolerance, as defined by either . . . [a] need for markedly increased amounts of opioids to achieve intoxication or desired effect [or] [a] markedly diminished effect with continued use of the same amount of an opioid . . . [and] (11) Withdrawal, as manifested by . . . [t]he characteristic opioid withdrawal syndrome . . . [or] [o]pioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.[30]
Individuals who exhibit two or three criteria over a twelve month period may be diagnosed with mild opioid use disorder.[31] Individuals who exhibit four or five criteria may be diagnosed with moderate opioid use disorder and individuals with six or more criteria may be diagnosed with severe opioid use disorder.[32] Opioid use disorder is one of several opioid-related disorders recognized by the APA and the opioid-related disorders are one of ten sets of substance-related disorders catalogued in the DSM-5.[33]
Opioid use disorder is associated with a number of health concerns, including lack of mucous membrane secretions, slowing of gastrointestinal activity, impairment of visual acuity, peripheral edema, and infections such as cellulitis, bacterial endocarditis, tuberculosis, hepatitis, and HIV.[34] Opioid use disorder is also associated with a heightened risk for attempted or completed suicide, as well as death due to accidental overdose, AIDS, and other medical complications.[35] An estimated seventeen-thousand deaths each year in the United States relate to opioid use,[36] and individuals with current or past opioid use disorder number approximately three million in the United States and sixteen million worldwide.[37] Opioid use disorder has a high global burden of disease; indeed, almost eleven million life-years have been lost due to opioid use-associated health problems.[38]
Treatment of an opioid overdose may involve the administration of an opioid reversal agent such as naloxone, which can be given through intravenous, intramuscular, endotracheal, or subcutaneous routes.[39] As discussed in more detail in Appendix A and Part III of this Article, approximately two-fifths of state benchmark plans do not cover any opioid reversal agents.
Treatment of opioid use disorder also may involve medically supervised opioid withdrawal, which is the administration of medication to an opioid-dependent individual to reduce the severity of withdrawal symptoms that occur when the individual stops using opioids.[40] Withdrawal symptoms include drug cravings, anxiety, restlessness, gastrointestinal distress, diaphoresis, and tachycardia.[41] Medications used to reduce the severity of these symptoms include opioid agonists such as methadone, partial agonists such as buprenorphine, mixed agonist/antagonists such as buprenorphine and naloxone, and alpha-adrenergic agonists such as clonidine.[42] Opioid withdrawal can be medically supervised in the inpatient and outpatient settings, although inpatient supervision is associated with higher opioid abstinence rates.[43] As discussed in more detail in Appendix A and Part III of this Article, some state benchmark plans expressly cover these medications while others expressly limit coverage of these medications in all or certain settings.
Treatment of opioid use disorder also may include psychosocial interventions, which are non-medical interventions that are designed to help patients control urges to use opioids.[44] These interventions include—but are not limited to—contingency management, relapse prevention, general cognitive behavior therapy, and treatments combining cognitive behavior therapy and contingency management.[45] These interventions can take place during individual, couples, family, and/or group counseling sessions, and can occur in both the inpatient and outpatient settings,[46] including in the psychiatric hospital,[47] substance abuse treatment facility,[48] residential treatment program,[49] partial hospitalization program,[50] intensive outpatient treatment therapy program,[51] and traditional outpatient clinic settings. Some individuals with opioid use disorder also may find mutual support groups, also known as peer-based recovery support groups and mutual aid groups, such as Narcotics Anonymous, helpful in recovering from opioid use disorder.[52] As discussed in more detail in Appendix A and Part III of this Article, some state benchmark plans expressly cover psychosocial interventions while others expressly limit coverage of psychosocial interventions as well as mutual support groups.
Opioid maintenance therapy is another approach to treating opioid use disorder. Designed to “block the euphoric and sedating effects of dependent opioids,” to “relieve the cravings,” and to “permit the patient to participate [more fully] in society,”[53] opioid maintenance therapy may include methadone, buprenorphine, or naltrexone.[54] When taken as directed, these medications can be both cost effective and clinically effective in reducing nonmedical opioid use as well as public health and safety problems relating to opioid use, including infectious diseases, death due to overdose, and crime.[55] As discussed in more detail in Appendix A and Part III of this Article, some state benchmark plans expressly cover these opioid maintenance therapies while others expressly limit their coverage.
Historically—and until quite recently—both public health care programs and private health plans distinguished between physical and mental disorders and provided inferior insurance benefits for treatment of all mental disorders, including opioid use disorder.[56] For example, Medicare Part B formerly imposed a fifty percent beneficiary coinsurance on outpatient mental health services—including individual, family, and group psychotherapy services—compared to the twenty percent beneficiary coinsurance traditionally applied to outpatient non-mental health services.[57] Many private health plans also used to provide inferior health insurance benefits for individuals with mental disorders by completely excluding their treatments and services from coverage or by providing less comprehensive coverage. For example, Kaiser Permanente’s 2012 Small Group Colorado Health Benefit Plan (Kaiser Plan) provided insurance coverage of “biologically-based mental illnesses,” but the Kaiser Plan only included six illnesses, including schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder within that definition.[58] Neither opioid use disorder nor any other substance-related disorder was included in that definition. Likewise, UnitedHealthcare’s traditional Certificate of Coverage provided coverage for “[b]iologically-based [m]ental illnesses,” but also defined the phrase to include schizophrenia, bipolar disorder, pervasive developmental disorder, paranoia, panic disorder, obsessive-compulsive disorder, and major depressive disorder.[59] Again, neither opioid use disorder nor any other substance-related or addictive disorder was included in that definition.
Although many states enacted parity laws designed to put mental health conditions on equal footing with non-mental health conditions, some of these parity laws specifically excluded substance-related and addictive disorders from protection as well.[60] As an illustration, New Mexico’s long-standing parity law requires group health plans in New Mexico to provide “mental health benefits” and to provide them at parity with “medical and surgical benefits.”[61] However, the New Mexico law specifically excludes treatments for “substance abuse” and “chemical dependency” from the definition of “mental health benefits.”[62]
During the past twenty-five years, developments in federal health insurance law have eliminated some—but not all—of these mental health benefit disparities, including opioid use disorder benefit disparities; however, a December 14, 2018, federal district court opinion striking down the ACA will reverse some of these advances. As background, President Bill Clinton signed the federal Mental Health Parity Act (MHPA) into law on September 26, 1996.[63] As originally enacted, MHPA prohibited large group health plans that offered medical and surgical benefits as well as mental health benefits from imposing more stringent lifetime and annual spending limits on their offered mental health benefits.[64] For example, MHPA would have prohibited a covered large group health plan from imposing a $20,000 annual cap or a $100,000 lifetime cap on mental health care if the plan had no annual or lifetime caps for medical and surgical care or if the plan had higher caps—such as a $50,000 annual cap or a $500,000 lifetime cap—for medical and surgical care.[65]
The application and scope of MHPA were very limited, however. As originally enacted, MHPA regulated only insured and self-insured group health plans of large employers, then defined as those employers that employed an average of fifty-one or more employees.[66] MHPA thus did not apply to the group health plans of small employers.[67] MHPA also did not apply to individual health plans, the Medicare Program, Medicaid non-managed care plans, or any self-funded, nonfederal governmental plan whose sponsor opted out of MHPA.[68] In terms of its substantive provisions, MHPA was neither a mandated offer nor a mandated benefit law; that is, nothing in MHPA required a large group health plan to actually offer or provide any mental health benefits for mental health conditions such as opioid use disorder.[69] Health plans were thus free—even after the enactment of MHPA—simply not to provide any benefits for opioid use disorder or any other mental health condition.[70] Indeed, individuals with substance use and addictive disorders—including opioid use disorder—were specifically excluded from MHPA’s modest lifetime and annual spending cap protections.[71] Finally, MHPA did not require parity between medical and surgical benefits and mental health benefits in terms of deductibles, copayments, coinsurance, inpatient day limitations, or outpatient visit limitations.[72]
Because of these limitations, President George W. Bush expanded MHPA twelve years later by signing into law the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).[73] MHPAEA built on MHPA by expressly protecting individuals with substance-related and addictive disorders, including opioid use disorder, and by imposing comprehensive parity requirements on large group health plans.[74] In particular, MHPAEA provided that any financial requirements (including deductibles, copayments, coinsurance, and other out-of-pocket expenses)[75] and treatment limitations (including inpatient day and outpatient visit limitations as well as non-quantitative treatment limitations such as medical necessity requirements)[76] that large group health plans imposed on mental health and substance use disorder benefits must not have been any more restrictive than the predominant financial requirements and treatment limitations imposed by the plan on substantially all medical and surgical benefits.[77] MHPAEA thus would have prohibited a large group health plan from imposing higher deductibles, copayments, or coinsurances, or lower inpatient day and outpatient visit maximums, on individuals seeking care for any mental health or substance use disorder listed in the current edition of the DSM or the World Health Organization’s International Classification of Diseases (ICD).[78] The previous sentence is very important: if a covered large group health plan actually offered insurance benefits for opioid use disorder, then the DSM’s and the ICD’s recognition and listing of opioid use disorder meant that the health plan would be prohibited from imposing higher financial requirements or more stringent treatment limitations on individuals seeking treatments and services for this condition.
Like MHPA, MHPAEA’s application and scope were initially limited. As originally enacted, MHPAEA regulated only insured and self-insured group health plans of large employers, defined as those employers that employ an average of fifty-one or more employees.[79] MHPAEA, like MHPA, did not apply to small group health plans, individual health plans, the Medicare Program, Medicaid non-managed care plans, or any self-funded, nonfederal governmental plans whose sponsors had opted out of MHPAEA.[80] In terms of its substantive provisions, MHPAEA was neither a mandated offer nor a mandated benefit law; that is, nothing in MHPAEA required a covered group health plan to actually offer or provide any benefits for conditions such as opioid use disorder.[81]
In late March 2010, President Obama responded to this limitation by signing the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (HCERA) into law (as consolidated, the Affordable Care Act (ACA)).[82] Best known for its controversial (and now repealed) individual health insurance mandate,[83] the ACA had two other sets of provisions that related to mental health parity and mandatory mental health and substance use disorder benefits. These provisions—until they were struck down by a federal district court on December 14, 2018—improved upon some of the limitations of MHPA and MHPAEA.
The first set of relevant ACA provisions extended MHPA’s and MHPAEA’s mental health parity provisions to the individual and small group health plans offered on and off the ACA-created health insurance exchanges.[84] After the ACA, many individual and small group health plans that previously discriminated against individuals with opioid use disorder through higher deductibles, copayments, and coinsurance rates—as well as lower inpatient day and outpatient visit limitations—were required to comply with MHPA and MHPAEA.
Legislation subsequent to the ACA continued to expand and promote compliance with MHPA and MHPAEA. For example, the 21st Century Cures Act (hereinafter “Cures Act”), signed into law by President Obama on December 13, 2016, required the Secretary of Health and Human Services (HHS), the Government Accountability Office, and/or other federal agencies, as appropriate, to issue a number of guidance documents, action plans, and reports addressing compliance with MHPA and MHPAEA.[85] By further example, the SUPPORT Act, signed into law by President Trump on October 24, 2018, required the Children’s Health Insurance Program (CHIP) to comply with MHPA and MHPAEA.[86]
On December 14, 2018, however, the United States District Court for the Northern District of Texas struck down the entire Affordable Care Act,[87] including the ACA provisions extending MHPA’s and MHPAEA’s mental health parity provisions to the individual and small group health plans offered on and off the ACA-created health insurance exchanges. To the extent that this District Court opinion (hereinafter “District Court Opinion”) stands, the ACA’s extension of mental health parity to individual and small group health plans is no longer valid.
The second set of relevant ACA provisions required certain health plans to actually provide mental health and substance use disorder benefits. That is, the ACA required individual and small group health plans,[88] exchange-offered qualified health plans,[89] state basic health plans,[90] and Medicaid benchmark plans[91] to offer “[m]ental health and substance use disorder services, including behavioral health treatment” in addition to nine other categories of essential health benefits (EHBs).[92] Even before the District Court Opinion, not every individual with health insurance benefited from these ten required EHB categories because some health plans, including self-insured health plans and grandfathered health plans, were exempt from the requirement to provide the ten EHBs.[93] In some states, such as Nevada, only a small percentage of state residents were covered by a health plan that was required to comply with the ACA’s EHB mandate, leaving the vast majority of residents without federally-mandated mental health and substance use disorder benefits post-ACA but pre-District Court Opinion.[94]
For those health plans that were required by the ACA to provide benefits within the ten EHB categories, the ACA’s statutory EHB requirements were unclear as to whether particular benefits—such as opioid use disorder benefits—were included. As a result, HHS issued its first set of final regulations implementing the ACA’s EHB requirements on February 25, 2013 (2013 Final Regulations).[95] The 2013 Final Regulations required states to select (or be defaulted into) a benchmark plan[96] that was sold in 2012 and that provided coverage for the ten EHB categories, including mental health and substance use disorder services,[97] and that served as a reference plan for health plans in each state. According to the 2013 Final Regulations, health plans in the state to which the EHB requirements applied were required to provide health benefits “substantially equal” to those provided by the state’s benchmark plan, including the benchmark plan’s covered benefits and excluded benefits.[98] Thus, the question of whether (and the extent to which) a particular health insurance policy or plan was responsible for providing (between years 2014 and 2016) benefits for a particular mental disorder—such as opioid use disorder—required an analysis of the applicability of the ACA’s EHB provision to the policy or plan as well as the content of the state’s selected benchmark plan.
The State of Nevada’s First Benchmark Plan can be used to illustrate the application of these rules. Nevada’s first benchmark plan was the Health Plan of Nevada Point of Service Group 1 C XV 500 HCR Plan (Nevada’s First Benchmark Plan).[99] If Nevada’s First Benchmark Plan included opioid use disorder benefits, then individual, small group, and other ACA-covered health plans in Nevada were responsible for providing these benefits in years 2014, 2015, and 2016.[100] On the other hand, if Nevada’s First Benchmark Plan did not include opioid use disorder benefits on March 31, 2012, then benefits for this disorder were not considered EHBs in Nevada, and individuals with opioid use disorder did not have coverage in years 2014, 2015, and 2016 unless their health plans voluntarily included such benefits[101] or unless they accessed separate state funds (only available in some states) for relevant treatments and services.[102]
Nevada’s First Benchmark Plan included coverage of both inpatient and outpatient services for substance abuse disorder, without limitation.[103] Because opioid use disorder is one type of substance abuse disorder, Nevada’s First Benchmark Plan thus required health plans that were required to comply with the ACA’s EHB requirements to provide coverage for medically necessary inpatient and outpatient treatments for opioid use disorder in years 2014, 2015, and 2016.
In regulations published on February 27, 2015 (the 2015 Final Regulations), HHS required states to select a new benchmark plan that was sold in 2014 and that would be effective for years 2017, 2018, and 2019 (Second Benchmark Plan).[104] The deadline for states to select that Second Benchmark Plan was June 1, 2015.[105] Nevada, for example, selected the Health Plan of Nevada Solutions Health Maintenance Organization Platinum 15/0/90% Plan.[106] Nevada’s Second Benchmark Plan again covered inpatient and outpatient services for “substance abuse disorder,” including opioid use disorder, although the Second Benchmark Plan set forth two limitations on such coverage.[107] First, the plan required prior authorization for all “non-routine” outpatient substance abuse treatments.[108] Second, the plan required prior authorization for all “inpatient” substance abuse treatment as well.[109]
On April 17, 2018, HHS published a third rule on this topic (the 2018 Final Regulations) giving states the option to select a new (i.e., third) benchmark plan that would become effective in the year 2020. However, the 2018 Final Regulations took a slightly different approach compared to the 2013 and 2015 Final Regulations.[110] In particular, the 2018 Final Regulations gave each state the flexibility to change the state’s second benchmark plan by: (1) selecting another state’s second benchmark plan; (2) replacing one or more categories of the state’s current EHBs with the same category or categories of EHBs set forth in another state’s second benchmark plan; or (3) selecting an entirely new benchmark plan so long as the new benchmark plan did not exceed the generosity of the most generous among a set of comparison plans, including the state’s second benchmark plan and any of the state’s options for a second benchmark plan.[111] State selections were due July 2, 2018.[112] Interestingly, only one state (Illinois) selected a new (i.e., third) benchmark plan as permitted by the 2018 Final Regulations.[113] All of the other states kept their second benchmark plans, which will now remain in effect through the end of year 2020, pending, of course, the outcome of any appeals of the District Court Opinion.[114]
To the extent the District Court Opinion is affirmed, the ACA’s EHB and benchmark selection requirements will fall. Remember, however, that the second benchmark plans were selected by states from preexisting health insurance plans that were already being sold in each state independent of the ACA. Plans like these will continue to be sold post-District Court Opinion. Therefore, these benchmark plans are helpful for understanding current and typical coverage of treatments and services for opioid use disorder. To this end, Appendix A and Part III below survey all current benchmark plans, including the second benchmark plans of all fifty states and the District of Columbia, as well as the third benchmark plan of Illinois. As discussed in more detail below, these benchmark plans demonstrate substantial variation in terms of their opioid use disorder coverage and limitations.
At the outset, it is important to note that only one state—Illinois—took advantage of the opportunity presented by the 2018 Final Regulations[115] to select a new benchmark plan that would improve insurance coverage of opioid use disorder treatments and services in that state. As discussed in Part II, all fifty states and the District of Columbia had the opportunity to change their second benchmark plans by: (1) selecting another state’s second benchmark plan; (2) replacing one or more categories of the state’s current EHBs with the same category or categories of EHBs set forth in another state’s second benchmark plan; or (3) selecting an entirely new benchmark plan so long as the new benchmark plan did not exceed the generosity of the most generous among a set of comparison plans, including the state’s second benchmark plan and any of the state’s options for a second benchmark plan.[116] This opportunity was open through July 2, 2018.[117] Illinois selected an entirely new benchmark plan (The Illinois Access to Care and Treatment (ACT) Plan) in accordance with the third option made available by the 2018 Final Regulations.[118]
The ACT Plan contains four new opioid-related provisions. First, it covers “at least one intranasal opioid reversal agent prescription for initial prescriptions of opioids with dosages of 50 MME or higher.”[119] In contrast, Illinois’ Second Benchmark Plan covered zero (or no) opioid reversal agents.[120] Second, the ACT Plan removes barriers to the prescription of medication-assisted treatment (MAT) of opioid use disorder by removing prior authorization requirements, dispensing limits, first-fail policies, and lifetime limit requirements otherwise applicable to MAT of opioid use disorder.[121] Third, the ACT Plan covers tele-psychiatry, including for opioid use disorder.[122] Finally, the ACT Plan limits opioid prescriptions for acute pain to no more than seven days.[123] Although Illinois was the only state to take advantage of the opportunity to incorporate opioid-specific provisions the state believed would help combat the opioid crisis, the District Court Opinion striking down of the ACA—if affirmed—will neutralize the impact of this missed opportunity in other states.[124]
At the outset, it is also important to note that many state benchmark plans—as currently written—contain comprehensive mental health and substance use disorder benefits that: (1) can be accessed by individuals with opioid use disorder; and (2) contain no limitations other than those that apply equally to physical health benefits. Missouri’s Second Benchmark Plan, for example, covers a wide variety of mental health and substance use disorder services, including: (1) inpatient services delivered in a hospital or other inpatient facility, including “psychotherapy, psychological testing, convulsive therapy, detoxification, and rehabilitation”; (2) outpatient services delivered in an outpatient department of a hospital as well as during an outpatient office visit; (3) day treatment services, defined as those services that are “more intensive than outpatient visits but less intensive than an overnight stay in [a] [h]ospital”; and (4) residential treatment services, defined as specialized twenty-four-hour treatment services provided in a licensed residential treatment center or intermediate care facility, including observation and assessment by a psychiatrist, rehabilitation, therapy, education, recreational, and social activities.[125] These covered services may be provided by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker, mental health clinical nurse specialist, licensed marriage and family therapist, or licensed professional counselor.[126] Although Missouri’s Second Benchmark Plan does impose a thirty percent coinsurance on in-network substance use disorder care and a fifty percent coinsurance on out-of-network substance use disorder care,[127] the plan imposes the same coinsurance percentages on non-mental health and non-substance use disorder care,[128] thus raising no issues under the financial requirement provisions set forth in federal mental health parity law, as discussed in Part II.[129]
The same is true of many other state benchmark plans as well. Virginia’s Second Benchmark Plan covers: (1) “[i]npatient [s]ervices in a hospital or other facility,” including “individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient’s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation”; (2) “[o]utpatient [s]ervices consisting of treatment in an outpatient department of a [h]ospital and office visits,” including “individual psychotherapy, group psychotherapy, psychological testing and medication management visits”; (3) partial day services; and (4) residential treatment facility services, including “observation and assessment by a psychiatrist” as well as “rehabilitation, therapy, education, and recreational or social activities.”[130] Virginia’s Second Benchmark Plan covers these services regardless of whether they are provided by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker, mental health clinical nurse specialist, licensed marriage and family therapist, or licensed professional counselor.[131] Although Virginia’s Second Benchmark Plan does impose a $500 copayment per day—up to a maximum of $1,500 per admission—on inpatient substance use disorder care,[132] Virginia imposes the same copayments on inpatient care for physical health conditions.[133] The copayments thus do not violate federal mental health parity law, as discussed in Part II, although they may raise an issue regarding the association between cost and access to inpatient substance use disorder care.[134] Because plans like the Missouri and Virginia plans will continue to be sold even if the District Court Opinion is affirmed, some insureds will continue to benefit from comprehensive mental health and substance use disorder benefits.
Some state benchmark plans expressly acknowledge the concept of mental health parity and/or expressly require compliance with mental health parity laws—in particular—with inpatient, outpatient, or prescription drug contexts. For example, Idaho’s Second Benchmark Plan states the following with respect to coverage of inpatient care: “The benefits provided for [i]npatient hospital services and [i]npatient medical services in this section are also provided for the care of [m]ental or [n]ervous [c]onditions, [a]lcoholism, [s]ubstance [a]buse or [a]ddiction, or any combination of these.”[135] Idaho’s Second Benchmark Plan contains a parallel statement in the context of outpatient care coverage: “The benefits provided for [o]utpatient [h]ospital [s]ervices and [o]utpatient [m]edical [s]ervices in this section are also provided for [m]ental or [n]ervous [c]onditions, [a]lcoholism, [s]ubstance [a]buse or [a]ddiction, or any combination of these.”[136] Kansas’ Second Benchmark Plan contains a parallel statement in the context of prescription drug coverage: “Psychotherapeutic drugs used for the treatment of [m]ental [i]llness and [s]ubstance [u]se [d]isorders [are covered] under terms and conditions not less favorable than coverage provided for other Prescription Drugs.”[137]
Some state benchmark plans expressly acknowledge the concept of mental health parity and/or expressly require compliance with mental health parity laws in all contexts—without specifying application to the inpatient, outpatient, or prescription drug contexts. For example, Massachusetts’ Second Benchmark Plan states: “The financial requirements and treatment limits for your mental health or substance abuse coverage can be no more restrictive than those for your medical and surgical coverage.”[138] Similarly, the New Jersey Benchmark Plan states: “Horizon BCBSNJ [(Blue Cross Blue Shield of New Jersey)] pays benefits for the [c]overed [c]harges a [c]overed [p]erson incurs for the treatment of [m]ental [i]llness or [s]ubstance [a]buse the same way Horizon BCBSNJ would for any other Illness, if such treatment is prescribed by a [p]ractitioner.”[139] Likewise, the Indiana Benchmark Plan states: “Coverage for the treatment of behavioral health and substance abuse conditions is provided in compliance with state and federal law.”[140] The Montana Benchmark Plan is very succinct in this respect: “Benefits for [c]hemical [d]ependency will be paid as any other Illness.”[141]
On the other hand, some benchmark plans contain no provisions requiring compliance with mental health parity law. For example, the Second Benchmark Plans of Alabama,[142] the District of Columbia,[143] Georgia,[144] and Wyoming[145] contain no provisions requiring compliance with state and/or federal mental health parity law.
Prior authorization (also called—with slight variation in meaning—prior certification, prior approval, or prior review [hereinafter prior authorization]) is the most common substance use disorder coverage limitation. That is, many state benchmark plans require an insured to request and obtain prior authorization for outpatient, inpatient, and/or other substance use disorder services from the individual’s health plan. Without such prior authorization, substance use disorder coverage may be denied, limited, or delayed. The twenty-eight states that contain some type of prior authorization requirement potentially applicable to substance use disorder care—including opioid use disorder care—include Arizona, Arkansas, Colorado, Connecticut, the District of Columbia, Florida, Hawaii, Idaho, Illinois (Second Benchmark Plan only), Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Vermont, and Wisconsin.[146] These prior authorization requirements are described in more detail at Appendix A.[147] Connecticut’s Second Benchmark Plan is noteworthy because its prior authorization requirement applies only to “outpatient treatment of opioid dependence,” but not to outpatient treatment of any other substance use disorder.[148] Why the Connecticut Plan singles out opioid use disorder—but not other substance use disorders—for prior authorization is unclear. Whether these prior authorization requirements violate mental health parity law depends on whether they are enforced and whether parallel prior authorization requirements exist in the context of offered non-mental health benefits.[149]
The ACA requires each state benchmark plan to list the number of covered drugs in each United States Pharmacopeia (USP) category and class.[150] USP categories relevant to opioids and opioid use disorder include analgesics and anti-addiction agents.[151] Within the analgesics category, classes relevant to opioids include long-acting analgesics and short-acting analgesics.[152] Within the anti-addiction agent category, classes relevant to opioid use disorder include opioid dependence treatments and opioid reversal agents.[153] Although there is substantial variation among benchmark plans, a review of Appendix A shows that many state benchmark plans cover approximately the following number of drugs in each relevant USP categories and classes: (1) ten long-acting opioid analgesics; (2) twelve short-acting opioid analgesics; (3) two opioid dependence treatments; and (4) one opioid reversal agent.[154]
That said, the Second Benchmark Plans of the following twenty states, as written, cover zero (i.e., no) opioid reversal agents: Alabama, Alaska, Arkansas, Florida, Hawaii, Illinois, Iowa, Louisiana, Michigan, Minnesota, Mississippi, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Tennessee, Texas, Utah, and Wisconsin.[155] If a state benchmark plan covers zero drugs within a particular USP class, such as the opioid reversal agent class, regulations implementing the ACA require plans that must comply with the ACA’s EHB provision to disregard the benchmark plan’s zero coverage and to cover at least one drug per USP class.[156] Before the District Court Opinion, then, plans required to comply with the EHB provision were required to cover at least one opioid reversal agent. However, when the District Court Opinion struck down the ACA, it struck down the EHB provision within the ACA. The result is that, if the District Court Opinion is affirmed, health plans in all states may permissibly cover zero opioid reversal agents unless some other non-ACA law—such as a state mandated benefit law—requires coverage of one or more opioid reversal agents.
It is noteworthy that the Third Benchmark Plan selected by Illinois, which would be effective in 2020, does cover one opioid reversal agent.[157] As noted above, Illinois’ Second Benchmark Plan covered zero opioid reversal agents.[158] Illinois may have made this change to respond to the opioid crisis. That said, if the District Court Opinion is affirmed, health plans in Illinois could revert to covering zero opioid reversal agents.
Some state benchmark plans expressly cover services provided to individuals with substance use disorders in a residential treatment facility.[159] Other state benchmark plans expressly exclude from coverage: (1) services provided to individuals with mental health conditions in general (or substance use disorders in particular) in a residential treatment facility, and/or (2) residential treatment services provided in another facility, such as a chemical dependency facility. Illustrative plans with exclusions include the Second Benchmark Plans of Alabama,[160] Florida,[161] Michigan,[162] Minnesota,[163] Nebraska,[164] North Dakota,[165] Rhode Island,[166] South Carolina,[167] Texas,[168] and Utah.[169]
Other state benchmark plans limit, but do not completely exclude form coverage, substance use disorder care provided in a residential treatment facility. For example, Iowa’s Second Benchmark Plan covers services provided for chemical dependency in a residential treatment facility, but only when such services are provided “on an intensive outpatient basis, or for partial hospitalization treatment, or for treatment that is provided as an inpatient at an acute level of care requiring medically monitored 24-hour registered nursing care under the supervision of a medical director.”[170] South Dakota’s Second Benchmark Plan contains a similar limitation; that is, benefits for care provided in residential treatment facilities are only available if “treatment is provided as an inpatient at an acute level of care with 24-hour registered nursing care under the supervision of a medical director.”[171] Oregon’s Second Benchmark Plan limits coverage of services provided in a residential facility to forty-five days.[172] The Second Benchmark Plans of Idaho and Vermont require prior authorization for services provided in a residential treatment facility.[173]
Some state benchmark plans expressly cover methadone as a treatment or service for opioid use disorder. Washington’s Second Benchmark Plan, for example, covers “[p]rescription [m]edications that are prescribed and dispensed through a substance use disorder treatment facility (such as methadone).”[174] Maryland’s Second Benchmark Plan covers “[m]ethadone [m]aintenance.”[175] Minnesota’s Second Benchmark Plan covers “opiate replacement therapy including methadone and buprenorphine treatment.”[176]
Other state benchmark plans expressly exclude methadone from coverage. Alabama’s Second Benchmark Plan excludes “[s]ervices related to narcotic maintenance therapy such as methadone maintenance therapy” when care is coordinated by an Expanded Psychiatric Services (EPS) provider.[177] Arkansas’ Second Benchmark Plan expressly excludes from coverage “[m]edications used to sustain or support an addiction or substance dependency.”[178] Delaware’s Second Benchmark Plan includes methadone in its list of “What Is Not Covered.”[179] Kentucky’s Second Benchmark Plan excludes “[m]ethadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents.”[180] Rhode Island’s Second Benchmark Plan provides that, “[t]his agreement does NOT cover methadone clinics and treatments,” and further provides that “[m]ethadone dispensed to treat chemical dependency is NOT covered.”[181] Wisconsin’s Second Benchmark Plan expressly excludes from coverage “[m]ethadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents.”[182] Although Massachusetts’ Second Benchmark Plan does not exclude methadone from coverage, the Massachusetts Plan does apply a prior authorization requirement to such coverage.[183]
Some state benchmark plans exclude mutual support groups from coverage. For example, Alaska’s Second Benchmark Plan excludes from coverage “voluntary support groups, such as Alanon or Alcoholics Anonymous.”[184] Connecticut’s Second Benchmark Plan excludes from coverage “[n]on-medical supportive counseling services (individual or group) for alcohol or substance abuse (e.g., Alcoholics Anonymous).”[185] Rhode Island’s Second Benchmark Plan is similar: “This agreement does NOT cover the following substance abuse treatment services: [r]ecreation therapy, non-medical self-care, or self-help training (e.g., Alcoholics Anonymous (AA), Narcotics Anonymous (NA) meetings/services).”[186] As a practical matter, AA, NA, and many other mutual support groups have no dues or fees (although they may take voluntary collections during meetings),[187] so this exclusion is only relevant to individuals who attend mutual support groups that charge members to participate.
The Second Benchmark Plan of Alabama limits individuals seeking inpatient mental health and substance use disorder care to coverage of thirty inpatient days and twenty outpatient visits per year.[188] Because the Alabama plan does not appear to contain comparable limitations applicable to non-mental health and non-substance use disorder care, these quantitative treatment limitations may violate mental health parity law. The Second Benchmark Plan of Mississippi contains similar quantitative treatment limitations; that is, seven inpatient days and twenty outpatient days per year.[189] Because the Mississippi plan does not appear to contain comparable limitations applicable to non-mental health and non-substance use disorder care, these limitations may likewise violate mental health parity law.
The Second Benchmark Plan of Alaska defines “chemical dependency” as “an illness characterized by physiological or psychological dependency, or both, on alcohol or a state-regulated controlled substance.”[190] The Alaska plan excludes from coverage: (1) “chemical dependency services and supplies related to the diagnosis or treatment of chemical dependency”;[191] (2) treatments for chemical dependency provided in the emergency room other than “medically necessary detoxification services” provided in the emergency room;[192] and (3) treatments for chemical dependency provided in the inpatient hospital setting, other than “medically necessary detoxification services” provided in the inpatient hospital setting.[193]
In addition to these general chemical dependency exclusions, the Second Benchmark Plan of Alaska contains specific exclusions that include opioid treatments and services. That is, the Alaska plan excludes coverage of diagnoses and treatments for substance abuse codes 303.0 through 305.9, among other codes.[194] The DSM-IV, the edition of the DSM to which the plan refers for purposes of definitions and other references, codes opioid dependence as 304 and opioid abuse as 305.5.[195] The result is that diagnostic and treatment services for opioid use disorder are not covered under the Alaska plan. In terms of its opioid use disorder coverage, the Alaska plan is the most restrictive plan among all the state benchmark plans that the Author has reviewed.
The extent to which a health insurance policy or plan must provide coverage for treatments and services—and parity in such coverage—for individuals with opioid use disorder following the December 14, 2018, United States District Court for the Northern District of Texas opinion (District Court Opinion) is relatively complex. First, it is important to note that the invalidation of the entire ACA—to the extent affirmed by the United States Court of Appeals for the Fifth Circuit and/or the United States Supreme Court—does not invalidate the original Mental Health Parity Act (MHPA), which President Clinton signed into law in 1996, or the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which President George W. Bush signed into law in 2008. The District Court Opinion also does not invalidate the 21st Century Cures Act, signed into law by President Obama in 2016, or the SUPPORT Act, which President Trump signed into law in 2018. Health plans that are governed by these four federal laws—as well as analogous state laws—must continue to comply with the mental health parity requirements set forth in these laws notwithstanding the District Court Opinion.
However, the District Court Opinion’s invalidation of the entire ACA—to the extent affirmed—includes an invalidation of the essential health benefits provision and the related requirement for states to select a benchmark plan to which individual health plans, small group health plans, and other health plans in the state must provide substantially similar benefits. The invalidation of the ACA also means that the expansion of mental health parity law provided for in the ACA no longer applies. In summary—and to the extent the District Court Opinion is affirmed—mental health parity law will revert to MHPA as expanded by MHPAEA, the 21st Century Cures Act, the SUPPORT Act, and more stringent state law.
To the extent the District Court Opinion is affirmed, the ACA’s EHB and benchmark selection requirements also will fall. Remember, however, that the Second Benchmark Plans were selected by the states from preexisting health insurance plans that were already being sold in each state independent of the ACA. Plans like these likely will continue to be sold post-ACA. Therefore, these benchmark plans are helpful for understanding current and typical health plan coverage (and limitations of such coverage) of opioid use disorder treatments and services.
The research presented in Appendix A to this Article reveals several points and trends relating to state benchmark plan coverage of opioid use disorder treatments and services. First, only one state—Illinois—took advantage of the opportunity presented by the 2018 Final Regulations to improve coverage of opioid use disorder treatments and services. To the extent the District Court Opinion is affirmed, however, the benefits of this opportunity will be lost for residents of Illinois. Second, many benchmark plans do provide comprehensive substance use disorder benefits that appear to be at parity with offered physical health care benefits. Third, some state benchmark plans expressly acknowledge or expressly require compliance with state and/or federal mental health parity laws. Fourth, prior authorization is the most common substance use disorder coverage limitation set forth in state benchmark plans. More than half of all states impose some type of prior authorization requirement on individuals seeking some form of substance use disorder care in at least one inpatient or outpatient context. Fifth, approximately two-fifths of benchmark plans cover no opioid reversal agents, although regulations implementing the ACA—which soon could be invalidated—require some health plans in these states to cover at least one opioid reversal agent. Sixth, some benchmark plans exclude or limit coverage of residential treatment facility care. Seventh, some state benchmark plans exclude methadone from coverage. Eighth, two states’ (Alabama’s and Mississippi’s) benchmark plans establish quantitative treatment limitations applicable to inpatient and outpatient mental health and substance use disorder care that do not appear to apply to non-mental health and non-substance use disorder care. As such, these limitations may violate mental health parity law. Finally, one state’s (Alaska’s) benchmark plan excludes coverage of all chemical dependency care, including opioid use disorder care. In the context of individuals with opioid use disorder, Alaska’s benchmark plan is the most limiting of all the benchmark plans reviewed by the Author.
The Author, who is trained in law and the medical humanities but not in epidemiology or public health, hopes this research is helpful to those who study the social determinants of health. To the extent a lack of health insurance coverage of opioid use disorder treatments and services is associated with a lack of access to health care and/or health itself, the coverage limitations identified in this Article may be worthy of review and modification by relevant stakeholders and policymakers.
| State | Benchmark Plan
(Issuer/Group: Product) |
Mental Health and Substance Use Disorder Coverage Provisions
(and Limitations Thereto) |
|---|---|---|
| 1. AL | Blue Cross and Blue Shield of Alabama: |
|
| 2. AK | Premera Blue Cross Blue Shield of Alaska: |
|
| 3. AZ | The State of Arizona: |
|
| 4. AR | HMO Partners, Inc.: |
|
| 5. CA | Kaiser Foundation Health Plan, Inc.: |
|
| 6. CO | Kaiser Foundation Health Plan of Colorado: |
|
| 7. CT | ConnectiCare Insurance Company, Inc.: |
|
| 8. DE | Highmark Blue Cross Blue Shield Delaware, Inc.: |
|
| 9. DC | Group Hospitalization and Medical Services, Inc.: |
|
| 10. FL | Blue Cross and Blue Shield of Florida: |
|
| 11. GA | Humana Employers Health Plan of Georgia, Inc.: | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Analgesics: Opioid Analgesics, Long-acting: 11; (2) Analgesics Opioid Analgesics, Short-acting: 12; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 2; (4) Anti-Addiction: Substance Abuse Treatment Agents: Opioid Reversal Agents: 1. (Summary at P.4). |
| 12. HI | Hawaii Medical Service Association: |
|
| 13. ID | Blue Cross of Idaho Health Service, Inc.: |
|
| 14A. IL (2017-2019) | Blue Cross Blue Shield of Illinois: |
|
| 14B. IL (2020) | Illinois Access to Care and Treatment Plan[210] |
|
| 15. IN | Anthem Insurance Companies, Inc.: | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Opioid Analgesics, Long-acting: 14; (2) Opioid Analgesics, Short-acting: 16; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 3; (4) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents: 1. (Summary at P.6). |
| 16. IA | Wellmark, Inc.: |
|
| 17. KS | Blue Cross and Blue Shield of Kansas, Inc.: | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Opioid Analgesics, Long-acting: 10; (2) Opioid Analgesics, Short-acting: 12; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 2; (4) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents: 1. (Summary at P.8). |
| 18. KY | UnitedHealthcare of Kentucky, Ltd.: |
|
| 19. LA | Louisiana Health Service & Indemnity Company: |
|
| 20. ME | Anthem Health Plans of Maine (Anthem BCBS):
PPO Off Exchange, Blue Choice, $30.00, $2,500 Deductible[216] |
“Authorization for Inpatient Mental Health and Substance Abuse services must be obtained through the behavioral health care manager.” (P.14). |
| 21. MD | CareFirst BlueChoice, Inc.: | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Opioid Analgesics, Long-acting: 10; (2) Opioid Analgesics, Short-acting: 2; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 2; (4) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents: 1. (Summary at 6).
2. Prior Authorization Required for Coverage of Inpatient Hospital Admissions for Mental Health and Substance Use Disorder Services. “Hospital admissions must be authorized or approved by the Mental Health and Substance Abuse Management Program. Prior authorization will be obtained by contracting providers.” (P.B-30). |
| 22. MA | Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.: |
|
| 23. MI | PriorityHealth: |
|
| 24. MN | HealthPartners, Inc.: |
|
| 25. MS | Blue Cross Blue Shield of Mississippi: |
|
| 26. MO | Healthy Alliance Life Co. (Anthem BCBS): | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Opioid Analgesics, Long-acting: 11; (2) Opioid Analgesics, Short-acting: 12; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 2; (4) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents: 1. (Summary at P.5). |
| 27. MT | Blue Cross and Blue Shield of Montana: | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Opioid Analgesics, Long-acting: 10; (2) Opioid Analgesics, Short-acting: 12; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 2; (4) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents: 1. (Summary at P.6). |
| 28. NE | Blue Cross and Blue Shield of Nebraska:
SG BCBSNE 2 Tier (Blue Pride Plus), Blue Pride Plus Option 102 Gold[224] |
|
| 29. NV | Health Plan of Nevada, Inc.: |
|
| 30. NH | Anthem: | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Opioid Analgesics, Long-acting: 11; (2) Opioid Analgesics, Short-acting: 14; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 2; (4) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents: 1. (Summary at P.5). |
| 31. NJ | Horizon Healthcare Services, Inc.: | 1. Relevant Prescription Drug Category and Class Counts. The plan contains the following relevant prescription drug category and class counts: (1) Opioid Analgesics, Long-acting: 10; (2) Opioid Analgesics, Short-acting: 12; (3) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Dependence Treatments: 2; (4) Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents: 1 (Summary at P.5). |
| 32. NM | Presbyterian Health Plan, Inc.: |
|
| 33. NY | Oxford Health Insurance, Inc.: |
|
| 34. NC | Blue Cross and Blue Shield of North Carolina: |
|
| 35. ND | Blue Cross Blue Shield of North Dakota: |
|
| 36. OH | Community Insurance Company (Anthem BCBS): |
|
| 37. OK | Blue Cross Blue Shield of Oklahoma: |
|
| 38. OR | PacificSource Health Plans: |
|
| 39. PA | Keystone Health Plan East, Inc.: |
|
| 40. RI | Blue Cross Blue Shield of Rhode Island: |
|
| 41. SC | Blue Cross and Blue Shield of South Carolina: |
|
| 42. SD | Wellmark of South Dakota: |
|
| 43. TN | BlueCross BlueShield of Tennessee: |
|
| 44. TX | Blue Cross Blue Shield of Texas: |
|
| 45. UT | Public Employees Health Program (PEHP): |
4. Mental Health Exclusions. The plan establishes the following exclusions applicable to mental health conditions: “1. Inpatient treatment for Mental Health without Pre-authorization, if required by the Member’s plan; 2. Milieu therapy, marriage counseling, encounter groups, hypnosis, biofeedback, parental counseling, stress management or relaxation therapy, conduct disorders, oppositional disorders, learning disabilities, and situational disturbances; 3. mental or emotional conditions without manifest psychiatric disorder or non-specific conditions; 4. Wilderness programs; 5. Inpatient treatment for behavior modification, enuresis, or encopresis; 6. Psychological evaluations or testing for legal purposes such as custodial rights, etc., or for insurance or employment examinations; 7. Occupational or recreational therapy; 8. Hospital leave of absence charges; 9. Sodium amobarbital interviews; 10. Residential treatment programs; 11. Tobacco abuse; 12. Routine drug screening, except when ordered by a treating physician.” (P.32). |
| 46. VT | The Vermont Health Plan, LLC: |
|
| 47. VA | Anthem Health Plans of Virginia (Anthem BCBS): |
|
| 48. WA | Regence BlueShield: |
|
| 49. WV | Highmark Blue Cross Blue Shield West Virginia:
Shared Cost Blue PPO grp NON-X, Gold Shared Cost PPO $1000[245] |
|
| 50. WI | UnitedHealthcare Insurance Company: |
|
| 51. WY | Blue Cross Blue Shield of Wyoming: |
|