Illinois becomes first and only state to change Essential Health Benefit-benchmark plan
CMS approves benchmark plan with mental health and opioid-related additions

 

[August 30, 2018] 

The Illinois Department of Insurance has become the first and only state in the nation to obtain approval for a revised Essential Health Benefit– benchmark. The new Access to Care and Treatment Plan includes measures to reduce opioid addiction and expand access to mental health services in Illinois.

“The Access to Care and Treatment (ACT) Plan is a critical component in the state’s efforts to provide adequate and compassionate mental health treatment, and combat the opioid crisis,” said IDOI Director Jennifer Hammer. “This isn’t just about rules and regulations, it’s about not giving up on people.”

“This epidemic is affecting every community and every demographic with tragic outcomes across the country,” Rauner said. “We must help people get the treatment they need. These changes to the EHB-benchmark will give many people who carry private insurance access to alternatives to help them deal with the pain from injury and reduce the number of Illinoisans becoming addicted to dangerous medications.”

The Essential Health Benefit (EHB)-benchmark plan is the basic set of insurance benefits that most health plans sold in the individual and small group markets in Illinois must cover. In April 2018, Federal Centers for Medicare & Medicaid Services (CMS) announced that states had until July 2, 2018 to submit changes for plan year 2020. IDOI partnered with clinicians and researchers to identify changes to the existing plan that would address mental health and substance use disorders.

“Illinois is leading the way nationally in implementing evidence-based solutions to address the opioid crisis and expand access to mental health services,” Hammer said. “These recent changes add yet another important tool to combat this pervasive public health crisis.”

Based on the research, expert recommendations, and feedback from two public comment periods, IDOI made five revisions to the existing plan. Beginning in 2020, private health insurance companies in Illinois offering plans on the individual and small group market will be required to:

• Cover alternative therapies for pain;

• Limit opioid prescriptions for acute pain;

• Remove barriers to obtaining Buprenorphine products for medically assisted treatment (MAT) of opioid use disorder;

• Cover prescriptions for at least one intranasal spray opioid reversal agent when initial prescriptions of opioids are dosages of 50MME or higher; and

• Cover tele-psychiatry care by both a prescriber and a licensed therapist.

“The scope and ambition of these new benefits are impressive,” said Illinois Department of Public Health Director Dr. Nirav D. Shah. “The ACT Plan supports our mission to promote the health of the people of Illinois by providing additional resources to prevent and treat opioid use disorder.”

The Centers for Disease Control and Prevention (CDC) issued guidelines in 2016 stating “non-pharmacological and nonopioid therapies are preferred for chronic pain.” In a systematic review, Dr. Michael Connolly of the Southern Illinois University (SIU) School of Medicine, who advised IDOI on the ACT Plan, found strong evidence for use of topical analgesics for treatment of acute and chronic pain. Alternative treatments for managing pain are not new but what the ACT Plan does is remove barriers to alternative treatments by requiring insurance companies to cover them. “The Act Plan makes alternatives therapies, like topical anti-inflammatories, affordable and accessible for consumers,” said Dr. Connolly.

In some cases, prescribing opioids may be appropriate. However, research indicates that long-term opioid use often begins with treatment for acute pain. Experts and the CDC guidelines suggest that when opioids are appropriate to treat acute pain the supply should be limited to no more than seven days. The ACT Plan limits the coverage for opioid prescriptions to treat acute pain to seven days to help reduce the risk of patients developing an opioid dependency by shortening the supply provided to treat acute pain.

The ACT Plan also requires insurance companies to cover a prescription for an intranasal opioid reversal agent with opioid prescriptions of 50MME or greater. The purpose is to decrease the risk of death from unintentional overdose by making sure consumers have a reversal agent on hand that could stabilize them until first responders arrive.

It removes barriers to treatment by preventing insurance companies from imposing prior authorization, fail first policies, dispensing limits, or lifetime limit requirements on medication assisted treatment (MAT) or opioid use disorder.

Another barrier that Illinois consumers often face is access to quality care. The ACT Plan makes treatment more readily available to those who need it by requiring insurance companies cover tele-psychiatry care by a prescriber or licensed therapist.

“Access to a mental health provider can be life-changing,” Hammer said. “With the ACT Plan requiring insurance companies cover tele-psychiatry, transportation or location will no longer be barriers to care.”

“As a person in long-term recovery from addiction and a clinician, I am grateful to Director Hammer and Gov. Rauner for making Illinois the leader in revising the EHB-benchmark,” said Licensed Clinical Social Worker David Vail. “Unfortunately, addiction still carries a stigma. Only 10 percent of patients who need treatment get it. This is a significant step in removing that stigma and providing treatment to those who may not have been able to afford it or travel to receive it. It will also increase the accessibility to wider ranging service points. If we can continue the momentum to treat this disease and discontinue punishing it, we have the potential for entire communities to get well and heal.”

Hammer has made meeting consumers at the time and place where they need help the most a priority of IDOI since she was confirmed as director by a bipartisan Senate in January 2017. During the 2017 Open Enrollment Period, IDOI staff visited all 102 counties in Illinois to assist with enrollment and educate consumers. They also provided information about consumers’ legal rights to mental health treatment and services.

“These changes to the benchmark are another step forward to ensuring the people of Illinois have access to comprehensive, quality mental health care,” said Dr. Kari Wolf, Chair of the Department of Psychiatry at the SIU School of Medicine. “These changes also build opportunities for us in the medical field to tackle the opioid epidemic that is ravaging our communities.”

Last week IDOI received a State Flexibility Grant from CMS to assist with implementation of the ACT Plan. The grant will allow IDOI to continue to partner with medical experts and other stakeholders to assess the revisions to the EHB-benchmark and their impact on Illinois consumers and the opioid crisis. The federal funds will allow IDOI to continue to explore future opportunities to revise the Illinois EHB-benchmark.

The approval comes days after Illinois Gov. Bruce Rauner signed a mental health package that included three major IDOI policy initiatives to improve access to mental health and substance use disorder treatment in Illinois.

This package, combined with the Act Plan, makes Illinois a national leader in fighting the opioid epidemic and advancing mental health parity.

“We continue to be committed to connecting Illinois consumers with the resources they need,” Hammer said. “Removing these administrative hurdles will help consumers get the treatment they need when they need it most. The Act Plan gives consumers the right treatment, at the right place, at the right time.

[Illinois Department of Insurance]