Benefit Flexibility
| Dec 02 2021

Time to Check Your MAT Coverage as Overdose Deaths Reach New High

Christine Livingston
Senior Associate, Mercer
Jennifer Wiseman
Principal, Mercer’s Law & Policy Group
Leena Bhakta
Principal, Mercer Health
Mary Kay O'Neill
Partner, Clinical Services Consultant

The CDC recently reported that, for the first time, the number of US overdose deaths surpassed 100,000 over a twelve-month period. In the wake of such a grim milestone, employers should ensure that their health plans cover Medication Assisted Treatment (MAT) as part of their commitment to the behavioral health needs of employees and their families. MAT, which is the use of FDA- approved medication (buprenorphine, naltrexone or methadone) in combination with behavioral health services to treat substance use disorders, allows a person to be stabilized on an outpatient basis and then to be treated as an outpatient rather than requiring inpatient or residential treatment. MAT is both more clinically effective and less costly than many other treatments for opioid use disorder. The use of MAT has also been shown to help people stay abstinent through the early phase of treatment when relapse is the most likely.

Employers sponsoring self-funded group health plans should also review any limits on MAT coverage—from blanket exclusions to standard medical management techniques—for Mental Health Parity and Addiction Equity Act (MHPAEA) compliance. MHPAEA has long required that any limit on a substance use disorder treatment be in parity with limits on the plan’s medical/surgical benefits. New for 2021, the Consolidated Appropriations Act (CAA) requires that group health plans prepare a detailed, written comparative analysis of all non-quantitative treatment limits (NQTLs), and disclose that analysis to the DOL (or a participant or beneficiary) on request. As we have previously reported, the DOL is already asking many group health plans to produce a written comparative analysis—and within tight timeframes (such as 7-14 days). A DOL representative recently stated that NQTLs on MAT are a focus of the agency’s current enforcement efforts.

We recommend that plan sponsors review any NQTLs on MAT coverage and ensure that the processes, strategies, evidentiary standards and other factors used to apply these NQTLs are comparable to and applied no more stringently than those applied to medical/surgical benefits. Employers should pay particular attention to NQTLs on MAT that the DOL has identified in 2016 guidance, 2019 guidance and the self-compliance tool, such as:

  • Covering methadone for pain management, but not covering methadone for opioid addiction
  • Requiring prior authorization to cover opiate-addiction medication due to its safety risk, but not requiring prior authorization for medications with similar safety risks used to treat medical/surgical conditions (e.g. pain medications such as oxycodone and fentanyl)
  • Imposing a nonpharmacological fail-first requirement before authorization of opiate-addiction medication, but not for authorization of prescriptions for medical/surgical conditions
  • Using nationally recognized treatment guidelines to establish preauthorization requirements or dosage limits for medical/surgical medications but setting MAT preauthorization requirements or dosage limits that deviate from nationally recognized treatment guidelines for opiate addiction

For any NQTLs applied to MAT, the plan sponsor should make sure it has a CAA-compliant, written comparative analysis ready to produce on request. If the plan’s TPA hasn’t prepared a comparative analysis of the NQTL, consider whether it makes sense to remove or modify the NQTL on MAT, or develop a CAA-compliant comparative analysis.

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