State mandates coverage for substance addictions

EQUAL  COVERAGE: Sharon Morello, rear right, nursing director at The Providence Center, speaks with registered nurses Pam LeBlanc, left, and Sue Hardy. / PBN PHOTO/ MICHAEL SALERNO
EQUAL COVERAGE: Sharon Morello, rear right, nursing director at The Providence Center, speaks with registered nurses Pam LeBlanc, left, and Sue Hardy. / PBN PHOTO/ MICHAEL SALERNO

An employee with cancer is likely to find support and encouragement at work. Another employee with an alcohol or substance addiction is more likely to try to keep the illness hidden because of stigma, even as medical professionals say both are treatable and recovery is possible.

A newly enacted state law will require insurance companies to provide coverage for mental health and substance-use disorders, including opioid addiction, under the same terms and conditions as coverage for other diseases.

The law, signed by Gov. Gina M. Raimondo in September, will require insurers to rely on criteria set by the American Society of Addiction Medicine for substance-use-disorder treatment, which patient advocates say will put everyone on the same page.

Generally, there was agreement among insurers and health care providers on initial stages of treatment, including for acute intoxication, medical complications and behavioral health and mental health treatment, according to Sharon Morello, nursing director at The Providence Center, a leading provider of mental health and substance-use treatment.

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But insurers often did not agree to cover continuing treatment such as ongoing counseling, which is essential in addiction diseases because relapse is so common, she said.

“The criteria we were using to say, what is the level of severity of this patient’s illness, and what’s the level of care that’s in this patient’s best interest, was not the same criteria that various health insurers used,” Morello said in a recent interview. “All had their own set of criteria. We had this arena that was never a flat playing field, to talk about, ‘I really believe the person I just admitted to an in-patient detox needs to not go to an out-patient setting because they’ve frequently failed in out-patient.’ ”

Insurers say they support the new law.

In a statement, Blue Cross & Blue Shield of Rhode Island said it had long invested in programs that support behavioral health, and collaborated with legislators and health experts on the new law. “The bills require payers to use American Society of Addiction Medicine standards for developing criteria for utilization-review determination,” said spokeswoman Stacy Paterno. “This is consistent with Blue Cross & Blue Shield of Rhode Island operations and we expect to continue to be a leader in supporting the behavioral health needs of our members.”

Addiction and substance-use disorders are a growing concern in the state, including among employers.

Rhode Island is among the states spending the most on health care for substance-use disorders, according to the U.S. Centers for Disease Control and Prevention.

Western states, including Oregon, Colorado and Washington, had some of the highest rates of opioid use in 2011. But the Ocean State is among the top 10 in the U.S. for per-capita health care costs spent on opioids.

Rhode Island spent $103 per resident in 2011, the CDC reported. Oregon spent the most, with $155 per capita, followed by Washington, Delaware, California, Colorado and Arizona.

For employers, addiction represents a growing concern.

Recovery Works RI, formed in 2014, is a coalition of individuals and employers working to increase awareness about substance-use disorders and recovery options.

The employer groups participating in the effort include the Greater Providence Chamber of Commerce, the Rhode Island Manufacturers’ Association and the Rhode Island Building and Construction Trades Association.

Businesses see the impact of addiction in lost productivity, increased absenteeism and increased workers’ compensation claims, according to Lisa Tomasso, Recovery Works community-relations and business-development associate. The nonprofit recently was awarded a $75,000 grant from the Rhode Island Foundation to increase its advocacy.

Part of the Recovery Works education effort, she said, is removing the stigma of a substance-use disorder, which can prevent employees from seeking treatment.

The new law was sponsored in the House by Rep. Patricia Serpa, D-West Warwick, who had initially introduced legislation that required parity in Rhode Island between mental health and physical health coverages. “We thought everything would be good. It wasn’t so good,” she said of the initial law.

“Their willingness to pay was subjective,” she said of insurers. “Depending on the insurance company, or who you were dealing with that day, you might get treatment covered.” •

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