States Are Ignoring ACA Requirements to Cover Addiction Treatment

AddictionInsurance plans are not covering the necessary addiction services, according to a report by The National Center on Addiction and Substance Abuse. None of the 2017 Essential Health Benefit benchmark plans have adequate addiction coverage; and more than two-thirds violate the affordable Care Act (ACA). There is no penalty for states or insurance plans that don’t comply with the law. “People with addiction may not be receiving effective treatment because insurance plans aren’t covering the full range of evidence-based care. Our review did not find a single state that covers all of the approved medications used to treat opioid addiction,” said Lindsey Vuolo, JD, MPH, of The National Center on Addiction and Substance Abuse.

The ACA requires plans to cover substance use disorder services, which are under essential-health benefits. The ACA also requires these services to be provided at parity, meaning that they are comparable to medical and surgical benefits. But the ACA does not identify which specific services should be covered. Each state chooses an essential health benefit benchmark plan to determine which addiction benefits must be covered by the ACA plans sold in that state. “The absence of sufficient coverage for medication-assisted treatment for opioid addiction is particularly alarming given the number of people dying or suffering on a daily basis. This kind of health care discrimination would never be tolerated during an epidemic for any other life-threatening disease,” said Samuel Ball, PhD, President and CEO at The National Center on Addiction and Substance Abuse. The report calls on states and insurers to comply with the law and cover the full range of effective addiction treatments. The following are key findings of the report:

  • Over two-thirds of plans contain language that violates ACA requirements for addiction benefits.
  • 18% of plans don’t comply with parity requirements.
  • No plans cover the full array of critical benefits without harmful treatment limitations.
  • 88% of the plan documents are not detailed enough to evaluate parity compliance and the adequacy of addiction benefits.

For more information, visit

Retail Healthcare Gains Popularity
The growing number of retail clinics is expected to transform primary healthcare and touch 30 million patients globally by 2022, according to a report by Frost & Sullivan. The global retail care market earned revenue of $1.35 billion in 2015 and is expected to reach $4 billion in 2022. Retail clinics are in pharmacies, grocery chains, supermarkets, and department stores, and address minor health issues. They have longer hours than do traditional clinics.

The retail clinic market is growing due to rising healthcare costs and a lack of access to primary care. In most developing countries, health insurance penetration is low and the out-of-pocket spending pinches patients. Rising premiums and higher deductibles are a concern for those with health insurance. A shortage of primary care physicians is resulting in longer wait times for doctor appointments, even in mature markets like the U.S.

Many patients see retail clinics as the second choice, and use then on weekends or after-hours, which limits patient volume. Opening retail clinics is financially impractical in some states due to regulations. The largest U.S. chain only has retail clinics in 33 states. Siddharth Shah of Frost & Sullivan said, “With increasing experience, retail players will expand their services…and experiment with…product-service bundling, telemedicine, and point-of-care technologies to enhance patient experience.” For more information, visit

Anthem to Tackle Rx Drug Abuse
Anthem Blue Cross launched the Pharmacy Home Program to help high-risk individual and group members reduce addiction to opioids and other prescription drugs. The program also aims to improve drug safety and healthcare quality by choosing a single home pharmacy for patients in the program. The program targets members who meet these criteria within a 90-day period:

  • Filled five or more prescriptions for a controlled-substance or filled 20 or more prescriptions, not limited to controlled substances.
  • Visited three or more health care providers for controlled substance prescriptions or 10 or more providers not limited to controlled substances
  • Filled controlled substances at three or more pharmacies or filled prescriptions for 10 or more pharmacies not limited to controlled substances.

The Pharmacy Home program notifies prescribers in writing of the decision to include the member in the program. The prescriber gets a three-month member prescription history. If the member does not change behavior within 60 days of the first letter, the member is asked to choose a single pharmacy location to fill all medications for a year, with a few exceptions. Those with a diagnosis or prescription history for HIV, sickle cell anemia, multiple sclerosis, cancer, hospice, and palliative care are exempted from the program.

Healthcare Issues Among Millennials
Transamerica Center for Health Studies (TCHS) finds that Millennials are struggling with the cost of healthcare while facing some health issues at a young age. The survey reveals the following:

  • The most common reason that the 11% of uninsured Millennials didn’t get coverage before the ACA deadline is that they did not know how to apply for insurance.
  • 60% of the uninsured are women; and 68% of the uninsured are unemployed.
  • 21% of Millennials can’t afford their routine healthcare expenses. An additional 26% can afford it, but with difficulty.
  • 70% say that cost is very important when looking for healthcare.
  • 66% of Millennials say that a $200 a month premium is not affordable.
  • Nearly half of Millennials skip care to reduce their healthcare costs.
  • More than half of Millennials have a chronic illness or health condition. The most common conditions are depression (17%), weight issues (15% overweight and 7% obesity), and anxiety disorders (14%).
  • 64% rely on their mom/step-mom as their primary source for health advice and healthcare guidance; 36% rely on their dad/step-dad; and 26% rely on their spouse or partner.

For more information, visit

Bill Offers Alternative to Obamacare
A health plan introduced by two Republicans promises to make good on what it calls ObamaCare’s three broken promises: universal coverage, cost control, and protection for the chronically ill. Yet the proposal spends no more money than the current system and it repeals almost all of ObamaCare’s regulations. Pete Sessions (R-TX), Chairman of the House Rules Committee and one of the sponsors of the legislation said, “ObamaCare tries to tell everyone what to do – every doctor, every patient, every employer and every employee. Our goal is to liberate people by empowering them to make their own choices and by freeing the marketplace to meet their needs.” The Senate version of the bill has been introduced by Sen. Bill Cassidy (R-LA).

The centerpiece of the proposal is a health insurance tax credit that applies dollar-to-dollar to insurance premiums and deposits to Health Savings Accounts. The credit will be the same for everyone, regardless of income. The tax credit sets a floor under the insurance people will have. Everyone will have access to insurance that looks a lot like well-managed, privately administered Medicaid, said John Goodman, a health economist who helped prepare the plan. People will have more options if they and their employers spend additional money – but those dollars will be unsubsidized.

The sponsors say the plan gives employers and employees new tools to control costs and that they will be able to convert waste, fraud and abuse into higher take-home pay by being smarter buyers of health care. Also, because of free market risk adjustment, health plans will specialize in the treatment of chronic conditions and will compete to solve those problems. The Sessions/Cassidy proposal is the freest enterprise reform ever introduced in the U.S. Congress, said Goodman. It minimizes and streamlines the role of the federal government and eliminates perverse incentives caused by federal tax and spending policies and unwise regulations. Even though introduced by Republicans, Goodman says there is much in the bill that Democrats will like. It has a much better chance of actually becoming law than any Republican proposal that I have seen so far. Goodman is the author of A Better Choice: Healthcare Solutions for America, the source of many of the provisions in the plan.

For more information, visit

A Profile of Uninsured Men
 At the start of 2015, there were over 27 million uninsured non-elderly adults in the U.S. Over half were non-elderly men, according to a report by the Kaiser Family Foundation. Men are more likely to be uninsured than are women and less likely to have Medicaid or other public coverage. Many men were not eligible for Medicaid before the ACA since the program excluded non-disabled adults without dependent children. Seventy-six percent of non-elderly uninsured men live in a household with at least one full-time worker, but more than half are low-income. Thirty-two percent of non-elderly uninsured men said they were having trouble paying medical bills in 2014.

Forty-four percent of non-elderly uninsured men are eligible for financial assistance under the ACA. In Medicaid expansion states, 55% of men are eligible for assistance, including 35% who are eligible for Medicaid. In non-expansion states, 33% are eligible for assistance, including just 2% who are eligible for Medicaid while 20% fall into the coverage gap.

A man’s likelihood of being uninsured varies based on where he lives. The uninsured rate for men ranged from a high of 25% in Texas to a low of 6% in Massachusetts. The following factors raise the risk for men to be uninsured: they have family incomes below 100% of the federal poverty level; they have less than a high school education; they are Black, Hispanic, and/or non-citizen immigrants. The uninsured rate for White men was 11%.

Only 36% of non-elderly uninsured men have a usual source of care compared to 67% of those with Medicaid and 77% of those with private coverage. Non-elderly men with health coverage are more than two times as likely to get preventive care compared the uninsured. Non-elderly uninsured men are more likely (32%) than non-elderly men with Medicaid (15%) or non-elderly men with private coverage (10%) to have had trouble paying medical bills in 2014. Men without coverage are more likely to have serious financial strain due to medical bills. In 2014, 27% of non-elderly uninsured men said that medical bills caused them to use up all or most of their savings, have difficulties paying for basic necessities, borrow money, or be contacted by a collection agency. In contrast, only 9% of non-elderly men with Medicaid and 7% of non-elderly men with private coverage experienced this kind of financial strain due to medical bills.

Since many uninsured men are in working families, small businesses and job placement offices may be effective outreach sites for information on health coverage. Identifying trusted contacts will be key to increasing enrollment. For example, low-income fathers may be connected to father’s organizations that could connect them to health coverage options. Other community-based organizations and agencies that serve men may also be effective including workforce development programs, child support agencies, and justice-system agencies.

People learn about health coverage options through multiple avenues, including word-of-mouth, mass media, and healthcare providers. Broad-based messages are effective in educating people about coverage while targeted messages are important in enrolling hard-to-reach groups, including low-income men and fathers. Some messages have been found to be effective, including discussing the importance of coverage for maintaining good health, the value of getting screenings and preventive care; the affordability of coverage options, the availability of financial help, and the financial protections of having coverage; and how coverage helps them be an effective provider for the family. Messaging about free in-person enrollment assistance has also been particularly useful. Findings also suggest that talking with fathers about their children’s health and health care coverage can be an effective entry point for discussing their own health and health coverage. For more information, visit

Workers Are Satisfied with Their Health Benefits
Sixty-six percent of workers are satisfied with their health benefits and express little interest in changing the mix of benefits and wages, according to a study by the Employee Benefits Research Institute and Greenwald & Associates. Fourteen percent would trade wages to get more health benefits, and 20% trade some health benefits for higher wages. Forty-four percent would give up a wage increase to maintain their health coverage.

However, the preference for health benefits over wages seems to be waning. From 2012 to 2015, the percentage of workers who were satisfied with their health benefits fell from 74% to 66%. At the same time, the percentage who want fewer health benefits and higher wages increased from 10% to 20%. If their coverage became taxable, 50% would continue with their level of coverage, up from 31% in 2011. Twenty-nine percent would switch to a less costly plan; 16% would shop for coverage directly from insurers; and 5% would drop coverage.

Forty-four percent want to continue getting coverage the way they do today; 39% want to choose their insurance plan, having their employer pay the same amount it spends toward that insurance, and pay the remaining amounts themselves; and 17% want their employer to give them the money, allowing the worker to decide whether to purchase coverage and how much to spend. Eight in 10 say choice of health plan is extremely important (41%) or very important (39%). For more information, visit 

Five Facts about the Small Business Health Care Tax Credit
The IRS wants you to know that, if you are a small employer, there is a tax credit that can put money in your pocket. The small business health care tax credit is available through the small business health options program, also known as the SHOP marketplace. Employers must have fewer than 25 full-time equivalent employees, pay an average wage of less than $50,000 a year, and pay at least half of employee health insurance premiums. The IRS offers these five facts about this credit:

  1. The maximum credit is 50% of premiums paid for small business employers and 35% for small tax-exempt employers.
  2. To be eligible, you must pay premiums on behalf of employees enrolled in a qualified health plan offered through a Small Business Health Options Program Marketplace or qualify for an exception to this requirement.
  3. The credit is for eligible employers for two consecutive taxable years beginning in 2014 or later. You may be able to amend prior year tax returns to claim the credit for tax years 2010 through 2013 in addition to claiming this credit for those two consecutive years.
  4. You can carry the credit back or forward to other tax years if you don’t owe tax during the year.
  5. You may get a credit and a deduction for employee premium payments. Since the amount of your health insurance premium payments will be more than the total credit, if you are eligible, you can still claim a business expense deduction for the premiums in excess of the credit.

For more information, see the small business health care tax credit page on For information about insurance plans offered through the SHOP Marketplace, visit


SCAN Health Plan to Referrals Seminar
SCAN Health Plan will present a seminar on “The Art of Referrals” at the Orange County Association of Health Underwriters Senior Summit, August 8 to 9. The Senior Summit, being held at Pala Resort and Spa, is hosted by the Orange County, Inland Empire and San Diego chapters of the Assn. of Health Underwriters. The seminar is designed for brokers who sell Medicare Advantage (MA) health plans. Many brokers are quickly adding MA plans to their portfolio given their rise in attractiveness coupled with the aging of baby boomers into the Medicare space. Attendees will get tips on how to prospect for referrals while learning the benefits of networking and niche marketing. After attending the session at the OCAHU Summit, brokers can get more in-depth seminars and training offered throughout the year by SCAN. For more information, visit

Seven Indicted in Workers Comp Case
Seven defendants are scheduled to be in Riverside County Superior Court after being indicted by a grand jury in a case in which $98 million was billed fraudulently. The charges stem from the operation of a workers’ compensation medical mill, spearheaded by chiropractor Peyman Heidary, and involving other medical providers. A workers’ compensation medical mill starts with a law firm that uses “cappers” to sign up clients who go to medical clinics that are in on the scheme. Patients go to multiple specialists and get multiple diagnostic tests, regardless of the injury. The purpose of the treatment is to inflate the medical bills sent to the insurance companies. If the insurance companies don’t pay the bills, there is a lien against the workers’ compensation case, so the bill never goes away. Once the bills and liens are established, those involved in the scheme can sell them to third party factoring companies at a reduced price. The factoring companies continue to attempt to collect on the bills and liens. The insurance companies can be assessed fines at the Workers’ Compensation Appeals Board for not paying on bills and liens, so the insurance companies will settle the bills and liens, although at a fraction of what the bill or lien is claiming is owed.

The first indictment charges chiropractor Peyman Heidary, 45, of Riverside; attorney Cary Abramowitz, 59, of Los Angeles, Ana Solis, 34, of Rancho Cucamonga, and Gladys Ross, 53, of Simi Valley, with 69 felony counts including conspiracy to commit insurance fraud, making a false insurance claim, making a false statement for the purpose of getting workers’ compensation benefits, money laundering, practicing medicine without a license, and capping. There also is one misdemeanor count of unlicensed practice of law.

The second indictment charges chiropractor Touba Pakdel-Nabati, 37, of Costa Mesa; Quynam Nguyen, 57, of Orange; and Jason Yang, 50, of Pasadena, with 38 felony counts including conspiracy to commit insurance fraud, making a false insurance claim, making a false statement for the purpose of getting workers’ compensation benefits, and capping. If convicted as charged, Heidary faces a potential maximum sentence of 97 years and 4 months in state prison; and Pakdel-Nabati, Nguyen, Yang, Abramowitz, Solis, and Ross each face a potential maximum sentence of 63 years and 4 months in state prison. The case is being prosecuted by Deputy District Attorneys Erika Mulhere, Matthew Murray, and Raymond Ramirez of the DA’s Financial Crimes Unit. 

EPIC Hires a Vice President
EPIC Insurance Brokers & Consultants (EPIC) hired Eric Leventhal for the firm’s employee benefit consulting practice. He will be based in San Francisco. Joining as a vice president, Leventhal brings 30 years of employee benefit experience to EPIC. He was an area vice president at Gallagher Benefit Services in San Francisco, focusing on client relationship management, benefit program strategy, and new business development. He has also held benefit consulting positions at Frank Crystal & Company, ABD Insurance, and Financial Services and Towers Perrin.


Benefit Brokers Continue to Increase Their Share of the Voluntary Market
According to an Eastbridge Consulting study, the benefit broker segment generated nearly $4.3 billion in new sales in 2015, up by almost 8% over 2014. The segment now accounts for 60% of all voluntary sales, up from 57% in 2014. Career agents still have the second highest share at 16%, even though their sales continue to decrease. In 2015, career-agent sales were down almost 6% compared to 2014. For more information, visit

Wellness Participants Like Their Plans
Sixty-two percent of wellness program participants say that all members of their health plan should join a wellness program. The May 2016 HealthMine survey finds that 47% say their own healthcare costs would go down that if wellness programs had 100% participation. Members say that their wellness program helped them do the following:

  • 62% lower their healthcare costs.
  • 38% take fewer sick days
  • 33% be more productive at work

The Equal Employment Opportunity Commission’s (EEOC) final ruling allows employers to offer members financial incentives worth up to 30% of individual health insurance premium costs as long as programs are voluntary and follow protections against discrimination. For more information, visit


Life Insurance Price Comparison Service for Scuba Divers offers a service that allows scuba divers to find life insurance at the best possible rates. Founder and CEO, Robert Bland said, “Life insurance shoppers who indicate that they intend to scuba dive only answer four short questions about the type and frequency of diving. In seconds, they can view the best rates for their profile, whether they are recreational or professional divers. For more information, visit

Medicare Set Aside Estimator And Medical Reserve Calculator
Care Bridge International launched a Medicare set aside estimator and Medical reserve calculator. An extensive medical claims database is used to forecast future medical costs. It includes prescription drug costs, which can average 40% or more of the total claim exposure for medical care and treatment. For more information, visit