Opioid dependence therapy is a combination of pharmacological agents and psychosocial therapy. Psychosocial therapy consist of four phases; assessment and treatment planning, induction, stabilization, and maintenance. Physicians should be aware of and adhere to currently accepted guidelines and recommendations for treating opioid dependent patients, including integrating psychosocial treatments and behavior modification strategies for optimal results. Clinicians must be educated on the new treatment modalities and regulations surrounding the use of these therapies.

Coverage for groups with 51 or more employees

The 2008 Federal Mental Health Parity and Addiction Equity Act (MHPAEA) which updated the 1996 Mental Health Parity Act is applicable to all self-insured group health plans with greater than 50 employees. In addition, large insured group health plans (over 50 employees) must also comply with MHPAEA and any subsequent changes to the law. The law includes an exception process to the MHPAEA requirements for those group health plans that can prove a significant increase in cost to provide coverage (2% in the first year and 1% in following years).

MHPAEA does not apply to:

• Medicaid managed care plans
• Medicare Advantage plans (unless sponsored by Employer)
• Federal Employee Plan (FEP)
• Non-federal governmental plans with less than 100 employees

The MHPAEA requires that a carrier or group health plan that provides coverage for mental health disorders or substance use disorders cannot impose financial requirements and treatment limitations that are more restrictive/less favorable than those applied to medical benefits. Generally, parity requirements include:

• Lifetime or annual limits on mental health or substance use disorder benefits
• Financial requirements (e.g., co-pays, co-insurance, deductibles)
• Out of Network coverage - if plan includes coverage for out of network medical/surgical benefits, the plan must also include coverage for out of network mental health and substance use disorders
• Quantitative treatment limitations (e.g., day limits, visit limits)
• Non-quantitative treatment limitations (e.g., medical management standards/policies), except to the extent that recognized clinically appropriate standards of care may permit a difference.

In addition, plans and group health plans must provide the internal policies, standards or criteria for medical necessity determinations to a current or potential member or contracting provider. Parity requirements are further and more specifically defined by regulation.

NOTE: MHPAEA does not mandate that a plan or group health plan provide coverage for mental health or for any specific mental illnesses or conditions; however, where a group health plan or plan elects to cover a mental health and substance abuse disorder, the law requires parity or general equivalence.

Opioid dependence therapy may be considered medically necessary for the following treatment stages in this order:

• Assessment and Treatment Planning (i.e., counseling, social support program, treatment goals, etc.)
  • One (1)-two (2) office visits weekly for the four (4)-weeks of initiation of therapy
• Induction - The medication is administered when an individual with an opioid dependency has abstained from using opioids for 12 to 24 hours and is in the early stages of opioid withdrawal.
  • Three (3) office visits per week for two (2)-weeks
• Stabilization - Begins after an individual has discontinued or greatly reduced their misuse of the problem drug, no longer has cravings, and experiences few, if any, side effects.
  • One (1)-two (2) office visits per week for eight (8)-weeks
• Maintenance - Occurs when a patient is doing well on a steady dose of medication.
  • One (1) office visit per month

Psychosocial treatment (i.e., cognitive behavioral, contingency management, coping skills training, etc.) may be considered medically necessary with buprenorphine drug treatment.

An individual must be evaluated by a licensed Drug and Alcohol therapist at least monthly while on maintenance medication.

Opioid dependence therapy is considered not medically necessary for all other indications.