Use of Medication-Assisted Treatment for Opioid Use Disorders in Employer-Sponsored Health Insurance: Out-of-Pocket Costs

02/12/2019

Truven Health Analytics

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ABSTRACT

This project assessed changes in Opioid Use Disorder (OUD) treatment utilization and expenditures in the employer-sponsored private health insurance market at two timepoints, 2006-2007 and 2014-2015, that mark the periods before and after implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA), the Affordable Care Act, the introduction and expanded use of new opioid treatment medications, and other initiatives to expand substance use disorder treatment access.

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on March 30, 2018.


 

TABLE OF CONTENTS

ABSTRACT

ACRONYMS

EXECUTIVE SUMMARY

INTRODUCTION

OBJECTIVES

METHODS

  • Data Sources
  • Study Population
  • Study Periods
  • Health-Related Expenses

RESULTS

  • Sample Characteristics
  • Health-Related Expenses
  • Coverage Changes Between 2007 and 2014

DISCUSSION

  • Cost Trends in OUD Treatment Related to MAT
  • Cost Trends in Other OUD Services
  • Limitations
  • Future Directions

NOTES

APPENDICES

  • APPENDIX A: ICD-9 and ICD-10 Diagnostic Codes for OUD
  • APPENDIX B: NDC Codes Identifying MAT
  • APPENDIX C: CPT, Revenue, and Healthcare Common Procedure Coding System Service Codes

LIST OF FIGURES

  • FIGURE 1: Total Number of Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, by Plan Type, 2004 and 2014
  • FIGURE 2A: Change in Total Payments During the Study Period for the Receipt of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018
  • FIGURE 2B: Annualized Percent Change in Payments During the Study Period for the Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007-2014 and 2007-2018
  • FIGURE 3A: Mean Co-payment for the Receipt of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018
  • FIGURE 3B: Annualized Percent Change in the Mean Co-payment for the Receipt of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007-2014 and 2007-2018
  • FIGURE 4: Proportion of Insurance Plans Covering Common SUD Services, 2003 and 2010
  • FIGURE 5: Cost of an Ideal 12-Month MAT Protocol by Health Plan Type if Services Were Delivered Entirely Out-of-Network

LIST OF TABLES

  • TABLE 1: National Measures of Inflation and Wage Growth, in Percent
  • TABLE 2: Types of Health-Related Expenses Considered in This Investigation
  • TABLE 3: Attributes of Insurance Plan Types Examined in This Investigation
  • TABLE 4: OUD Treatment Service Category Definitions
  • TABLE 5: Inflation Factors Used to Calculate Projections
  • TABLE 6A: Characteristics of Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, Total and by Plan Type, 2007
  • TABLE 6B: Characteristics of Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, Total and by Plan Type, 2014
  • TABLE 7A: Average Payment per Unit of Service in 2007, 2014, and 2018 for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, Annualized Percent Change Between 2007 and 2014, and Projected Change Through 2018
  • TABLE 7B: Change in Total Payments During the Study Period for the Receipt of Services Outside of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018
  • TABLE 8A: Average Deductibles and Premiums for Employer-Sponsored Health Insurance from the 2007 and 2014 KEHB
  • TABLE 8B: Combined Average Deductibles and Premiums for Employer-Sponsored Health Insurance from the 2007 and 2014 KEHB
  • TABLE 9: Co-payments for the Receipt of Common OUD Treatments for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018
  • TABLE 10: Mean Co-payment for Services for the Receipt of Common OUD Treatments Outside of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, by Plan Type, 2007, 2014, and 2018
  • TABLE 11: Co-insurance Rates for the Receipt of Common OUD Treatments for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007 and 2014
  • TABLE 12: Mean Co-insurance Rates for the Receipt of Common OUD Treatments Outside of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, by Plan Type, 2007 and 2014
  • TABLE 13: Median Out-of-Network Amount Paid for the Receipt of Common OUD Treatments for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007 and 2014
  • TABLE 14: Proportion of Service Received Out-of Network Services for Common OUD Treatments for Enrollees in Larger Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007 and 2014
  • TABLE 15: Estimated Effect, per Enrollee in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, of Lack of Coverage on Out-of-Pocket Expenditures for Common OUD Treatment Services, by Plan Type, 2007 and 2014
  • TABLE 16: Median Out-of-Network Amount Paid for the Receipt of Common OUD Treatments Outside of the Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD,by Plan Type, 2007, 2014, and 2018

 

ABSTRACT

This project assessed changes in the amount paid for medication-assisted treatment for opioid use disorder (OUD) across 2 years, 2007 and 2014, and projected the changes to 2018. These years were chosen because they include periods before and after implementation of federal legislation designed to increase access to general health care and behavioral health care, and they encompass a time when new medications to treat OUD were introduced. We used the Truven Health MarketScan® Commercial Claims and Encounters Database of private employer-sponsored health plans (enrollees aged 12-64 years). We also used data from the Kaiser Employer Health Benefits Survey and coverage trends from the Brandeis Health Plan Surveys. Using recommendations from the American Society of Addiction Medicine[1] and the Substance Abuse and Mental Health Services Administration,[2] we approximated the ideal treatment protocol for a typical individual with OUD, then approximated the total payments to physicians (combined insurance and out-of-pocket) to deliver that protocol. We found that the total payments for the ideal protocol rose from $5,927 to $6,886 based on the median price paid for each component. We found that the payments for nearly all types of OUD treatment services rose between 2007 and 2014, except for the payments for psychotherapy provided by psychiatrists or other physicians--a service for which the codes used for billing changed during the period under investigation making comparability difficult. The increase in the median payment for all other services, with the exception of outpatient detoxification, was greater than the increase in inflation during the study period. We also explored changes at the plan type level, and found that in 2014 a greater share of individuals with OUD were enrolled in plans with higher deductibles than in 2007, which would increase the out-of-pocket expenses experienced by those individuals. This increased out-of-pocket burden on patients may act as a barrier to optimal service utilization for individuals with OUD.

 

ACRONYMS

The following acronyms are mentioned in this report and/or appendices.

ASAM American Society of Addiction Medicine
 
BH Behavioral Health
BLS Bureau of Labor Statistics
 
CCAE Commercial Claims and Encounters
CDHP Consumer-Directed Health Plan
CPI Consumer Price Index
CPT Current Procedural Terminology
CSAT SAMHSA Center for Substance Abuse Treatment
 
DX Diagnosis code
 
ED Emergency Department
EMTALA Emergency Medical Treatment and Labor Act
 
FDA Food and Drug Administration
FIL Buccal Film
FQHC Federally Qualified Health Center
 
GER Gluteal Extended Release
 
HDHP High-Deductible Health Plan
HMO Health Maintenance Organization
 
ICD-9 International Classification of Diseases, Ninth Revision
ICD-10 International Classification of Diseases, Tenth Revision
IM Intramuscular
 
KEHB Kaiser Employer Health Benefits Survey
 
MAT Medication-Assisted Treatment
MM Mucous Membrane
 
N/A Not Available
NDC National Drug Code
NSD Not Sufficient Data
 
OR Odds Ratio
OUD Opioid Use Disorder
 
POS Point of Service
PPO Preferred Provider Organization
 
Rev Revenue code
RHC Rural Health Clinic
Rx Prescription fill
 
SAMHSA   Substance Abuse and Mental Health Services Administration  
SD Standard Deviation
SL Sublingual
SUD Substance Use Disorder
 
TAB Tablet
TMS Transcranial Magnetic Stimulation
Tx Treatment code

 

EXECUTIVE SUMMARY

Introduction

Out-of-pocket expenditures--the amount of money that patients are responsible for paying for their health care--are often a barrier to treatment for individuals with substance use disorders (SUDs).[3] The expenditures can include cost-sharing, which the U.S. Department of Health and Human Services website Healthcare.gov defines as "the share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, co-insurance, and co-payments, or similar charges."[4] Out-of-pocket expenditures also include the amount paid for services for which an individual's insurance does not provide coverage, which would be all services for individuals with no insurance.

Our analysis estimated the typical components of out-of-pocket expenses experienced by individuals who receive medication-assisted treatment (MAT) for opioid use disorder (OUD) and are enrolled in one of the three most common types of insurance plans. Additionally, to help provide a fuller picture of the expenses individuals incur, we included the average premium and contributions associated with those plan types. The out-of-pocket expenses are calculated and premiums and contributions are identified for 2007 and 2014. The premiums and contributions then were projected for 2018, and the out-of-pocket expenses were evaluated for the projection.

We selected the years 2007 and 2014 because they represent timepoints before and after the implementation of two laws with provisions intended to improve coverage for SUD treatment. Existing research shows that these laws increased the proportion of plans that offer any coverage for OUD services.[5] However, less research has focused on the extent to which these laws influenced out-of-pocket expenditures from patients. The projected year of 2018 is in the near future, but it allows enough time for key aspects of the major legislation that was passed to be implemented. These projections trend 2014 data forward but do not account for changes such as new federal regulations or changes in recommended treatment that may occur in the interim.

Objectives

This optional component of the project is a supplement to the main task report and summarizes the out-of-pocket expenses faced by individuals with OUD by type (deductible, co-payment, co-insurance) for an individual receiving a standard, guideline-concordant episode of MAT treatment. We compared these changes to benchmarks for inflation and wage growths to understand whether insured individuals faced higher expenses over time. This report includes data tables for the years mentioned, including projections for the future.

Methods

Data. We used data from the Truven Health MarketScan® Commercial Claims and Encounters (CCAE) Research Database for calendar years 2007 and 2014. The MarketScan CCAE Database contains private insurance claims from approximately 150 large employers for employees, their dependents, and early retirees. It is the largest commercial convenience sample in the United States.

Study population. We included private employer-sponsored health plan members, which encompassed employees, spouses, and dependents aged 12-64 years. We excluded enrollees younger than 12 years because of the low prevalence of OUD and enrollees older than 64 years because of Medicare eligibility and the possibility of having secondary insurance. We required at least 10 out of 12 months of enrollment in each calendar year to capture a complete or nearly complete treatment picture for each individual. We excluded plans (and all of their enrollees) that lacked prescription drug claims because of the importance of having complete service records for each enrollee and the need to capture use of MAT. We subdivided our analysis into four plan types and then created a separate all-plan category. The four plan types were health maintenance organizations (HMOs), preferred provider organizations, point of service (POS) plans, and a combined group of consumer-directed health plans and high-deductible health plans (CDHP/HDHP). We excluded claims covered by capitated plans that did not include reimbursement information.

Study periods. This study assessed changes in the levels and types of out-of-pocket expenses for patients receiving OUD treatment paid by employer-sponsored health insurance plans at two points in time--one before (calendar year 2007, i.e., Time 1) and one after (calendar year 2014, i.e., Time 2) implementation of major federal legislation enacted to increase insurance coverage and expand access to coverage of behavioral health care. We also used the results of our Time 2 analysis to inform estimates of projected out-of-pocket costs in 2018.

Analytic file. Our analytic file was constructed at the claims level to allow us to report on utilization and spending in aggregate for each category of plan we considered, as well as at the individual level. We used source claims-level analytic files, which included all inpatient admissions, outpatient services, and prescription drug fills. We categorized the individual claims records to create service categories and to construct the financial variables. The summary spending variables totaled the amount paid for a service, which included the insurer payment and beneficiary out-of-pocket expense.

Variable definitions. We constructed variables to identify individuals with an OUD, to characterize the sample and health plans, and to define service types. Below we describe how we defined each of these variables.

  • Opioid use disorder. The analytic data files included members with an OUD, defined as either having an OUD diagnosis or receiving OUD treatment, presuming that individuals receiving treatment qualified for an OUD diagnosis even if the diagnostic code was missing from the claims record. Specifically, individuals were classified as having an OUD and included in the analytic files if they: (1) had two or more outpatient visits on different days or one inpatient stay with an OUD diagnosis in any claims field; (2) had a MAT prescription fill; or (3) had a MAT administration procedure code for buprenorphine/naloxone, naltrexone, or methadone.

  • Enrollee and plan characteristics. The analytic files included member age, sex, relationship to insured (employee, spouse, or dependent), and physical and behavioral health conditions. They also included the number of months enrolled and health plan type. We also included information on the type of health insurance plan for the four primary plan categories defined above.

  • Service categories. We classified all OUD treatment services into specific service categories using Current Procedural Terminology codes, revenue codes, Healthcare Common Procedure Coding System codes, prescription drug National Drug Codes, and codes to identify the place of service (e.g., physician's office). We defined the following service categories: inpatient treatment (including detoxification), outpatient detoxification, residential services, intensive outpatient or partial hospitalization services, emergency department visits, outpatient physician office visits, and psychotherapy. Use of MAT was captured through the prescription claims codes for buprenorphine and buprenorphine/naloxone.

  • Utilization. We created variables for the frequency of use for each of the OUD-related services considered within each of the four plan categories specified above, as well as across all insurance plan categories for which an individual had a diagnosed OUD.

  • Financial variables. From health expenses, defined below, we computed variables to reflect insurer and individual spending. This included the mean and median of expenditures for each category of services. The variables included total provider payment, co-payment amount, co-insurance rate, and whether the service was delivered in or out of the insurance plan's provider network. We also considered premium and deductible data from the Kaiser Employee Health Benefits Survey and plan coverage from the Brandeis Health Plan Surveys.

Types of health expenses. We considered many types of expenses that are related to health care for individuals with OUD. First, we considered the price paid for services. This price includes the amount paid by the insurer and the out-of-pocket expenses experienced by the plan beneficiary, including co-insurance and co-payments. These results were calculated using data from the MarketScan CCAE Database. Second, we considered the price of insurance (i.e., premium) and the plan deductibles. These data were collected from the Kaiser Employee Health Benefit Survey. We specifically considered the portion of the plan premium that employees were responsible for paying. Lastly, we considered changes in plan coverage over time using data from the Brandeis Health Plan Survey.

Analytical approach. We calculated the amount paid per service using the median total payment, combining insurer and beneficiary payments. This was done at the claims level across all insurance plan types, and then separately for each individual plan type. We calculated the co-payments charged for each service by calculating the mean co-payment charged for all services, as well as the median co-payment charged for services which charged any co-payment. We also considered trends in the proportion of services with any co-payment charged between 2007 and 2014. We calculated the mean co-insurance rate for each service, and the median co-insurance rate when any co-insurance was charged. As with co-payments, we evaluated whether there was a change in the proportion of services with any co-insurance charged over time. To calculate the payments for services not paid for by insurance, we considered median amount paid for each service when the service was provided outside of a beneficiary's insurance network. We estimated the impact of lack of coverage on the average patient by using data on the proportion of health plans that did not provide coverage for specific OUD services from the Brandeis Health Plan Survey. Based upon Time 2 total payments, co-payments, and out-of-network payments we projected results to future years using appropriate health sector specific adjustment factors from the Bureau of Labor Statistics.

Results

Using recommendations from the American Society of Addiction Medicine[6] and the Substance Abuse and Mental Health Services Administration,[7] we approximated the ideal treatment protocol for a typical individual with OUD as 18 physician office visits, 15 psychotherapy visits, and 12 monthly buprenorphine prescription fills. The amount paid for this bundle increased from $5,927 to $6,886 based on the median price paid for each component. This corresponded to a 2.2 percent annual increase on average, which was slightly above the average rate of inflation of 1.9 percent during that period. Moreover, there was a large increase in average plan deductibles and the proportion of premiums paid by employees during the study period. This resulted in patients experiencing larger amounts of health care costs before their insurance benefits took effect. The combination of the average deductible payment and the employee's share of the premium increased at rates ranging from 10.3 percent per year for individuals enrolled in HMOs to 4.8 percent per year for individuals enrolled in CDHPs/HDHPs. However, CDHPs/HDHPs had the highest baseline level of premiums and deductibles, and therefore they remained the most expensive for patients that reached the deductible during both study periods. Moreover, there was significant movement in our sample toward CDHP/HDHP insurance.

We found that even with higher deductibles, patients with OUD still experience significant levels of co-insurance, which may reflect that costs of care for individuals with OUD often exceed the deductible. In fact, we found that the mean level of co-insurance paid per unit of service for the most common opioid treatment services increased during the study period from 5 percent to 6 percent per visit for psychotherapy and from 1 percent to nearly 3 percent per buprenorphine prescription fill.

The levels of co-payments for services did not increase dramatically during our study period, which reflects the fact that other forms of cost-sharing have replaced co-payments in shifting service costs from insurers to patients. The mean payment for an office visit decreased from $13 to $11, and the mean payment for a buprenorphine/naloxone prescription fill decreased from $33 to $27. These results indicate that co-payments had less of an impact on patient expenditures over time relative to the growth in deductibles and co-insurance.

Results from the Brandeis Health Plan Survey indicated that insurance coverage for buprenorphine expanded dramatically during the period considered, particularly among POS and HMO health plans. Because of the high cost of buprenorphine for individuals without insurance coverage, this represents a massive out-of-pocket expense to patients that has been mitigated since legislation has changed.

Directions for Future Research

Our main task results revealed that the growth in the population with OUD exceeded the rate of growth in the number of individuals that use MAT treatment services, which may indicate that the expenses are deterring use. We have added to the literature on the cost of treatment for individuals receiving treatment for OUD, but additional research is needed to understand how much money individuals are willing to pay for OUD services. It is possible that individuals are more willing to pay for OUD treatment services now than in the past because the characteristics of the populations receiving treatment have changed or because the perceived value of treatment has risen. It is also important to consider the role of Medicaid in service use over time.

 

INTRODUCTION

This analysis is a supplement to the commercial opioid use disorder (OUD) main task report titled Use of Medication-Assisted Treatment (MAT) for Opioid Use Disorders in Employer-Sponsored Health Insurance. It estimated the typical components of out-of-pocket expenses experienced by individuals who received medication-assisted treatment (MAT) for OUD and who were enrolled in one of the three most common types of insurance plans. Additionally, to help provide a fuller picture of the expenses incurred by individuals, we included the average premium and contributions associated with those plan types. The out-of-pocket expenses were calculated and premiums and contributions are identified for 2007 and 2014.

We selected the years 2007 and 2014 because they represent timepoints before and after the implementation of two laws with provisions intended to improve coverage and access to SUD treatment. Existing research shows that these laws increased the proportion of plans that offer any coverage for OUD services.[8] However, less research has focused on the extent to which these laws influenced out-of-pocket expenditures for individuals with OUD.. The projected year of 2018 is in the near future, but it allows enough time after the passage of major legislation for spending trends to normalize. These projections trended 2014 data forward, but did not account for factors such as new federal regulations or changes in recommended treatments that may occur in the future.

 

OBJECTIVES

This Optional Task Analysis summarizes the health expenditures faced by individuals with OUD by type (premium, deductible, co-payment, co-insurance) for an ideal treatment protocol for OUD involving buprenorphine/naloxone MAT, as well as other related SUD treatment services such as detoxification. Using recommendations from the American Society of Addiction Medicine (ASAM)[9] and the Substance Abuse and Mental Health Services Administration (SAMHSA),[10] we attempted to quantify this protocol. The results are presented stratified by plan type where data were available. We compared the rates of changes to measures of inflation and wage growth during the same time periods. We also formulated projections of costs into future years. This report is a supplement to the main task report produced under this contract.

The Main Task Analysis Report[11] investigated changes in OUD treatment utilization and expenditures in the employer-sponsored private health insurance market at two timepoints (2006-2007 and 2014-2015), which overlap with the timepoints we consider. It contains results of an investigation to determine whether access to treatment among individuals with private insurance improved over time and to identify where treatment gaps (e.g., lack of coverage for specific types of services) and access barriers (e.g., high out-of-pocket costs) still may exist. It provided important information that is not considered in this report, because it analyzed service use at the treatment episode-level, rather than the claim level. Although the current analysis looked at the prices associated with various services and a hypothetical course of treatment, the analysis in the main report evaluated how treatment episodes for actual individuals in OUD care changed over time.

 

METHODS

Data Sources

We used the Truven Health MarketScan Commercial Claims and Encounters (CCAE) Research Database for calendar years 2007 and 2014. The MarketScan CCAE Database contains private insurance claims (primarily large group plans) from approximately 150 large employers for employees, their dependents, and early retirees. The MarketScan CCAE Database is the largest commercial convenience sample in the United States. Although the database has fluctuated in size and contributors over time, it has maintained the same age and sex distribution as reported by the U.S. Census Bureau for individuals with employer-sponsored insurance.

We included private employer-sponsored health plan members, which comprised employees, spouses, and dependents aged 12-64 years. We excluded enrollees younger than 12 years because of the low prevalence of OUD and enrollees older than 64 years because of Medicare eligibility and the possibility of having secondary insurance. We required at least 10 out of 12 months of enrollment in each calendar year to capture a complete or nearly complete treatment picture for each individual. We excluded plans (and all of their enrollees) that lacked prescription drug claims because of the importance of having complete service records for each enrollee and the need to capture use of MAT, and we excluded claims covered by capitated plans that did not include reimbursement information. Our unit of analysis was the medical claim. A claim is a bill for a specific service created by a provider and submitted to an insurer or patient. We did not track changes in individual expenditures over time; instead, we calculated the payments for treatment based on medical claims in two time periods.

We also used the results of the Brandeis Health Plan Surveys on Alcohol, Drug Abuse, and Mental Health Services.[12] These nationally representative surveys provide information and coverage on how various mental health and SUD treatment services offered by health insurance plans of various categories change over time.[13] We used a weighted sample methodology to determine that the 2003 survey represented 7,469 private health plans, and the 2014 survey represented 6,974 health plans.[14] Thus, the results are quite representative of insurance coverage in the United States. We used the estimated proportion of plans that provide coverage for "opioid treatment programs" reported in the Brandeis Health Plan Surveys[15] as a proxy measure of the proportion of insurance plans in each category that provided coverage for specialty OUD treatment coverage. Services considered specialty OUD treatment included residential, intensive outpatient or partial hospitalization, detoxification, and administration of methadone.

We also used data from the Kaiser Employer Health Benefits Survey (KEHB), for the years 2007 and 2014. This survey is conducted nationally and is representative of the insurance coverage available to privately and publicly employed individuals and their families in the United States. It includes information on premiums, deductibles, and cost-sharing and is gathered from a representative group of employers in the United States.[16]

Finally, we used inflation and wage growth data from the Bureau of Labor Statistics (BLS) to calculate estimated industry-specific rates of change to use for projecting our 2014 data to 2018 and as benchmarks against which to compare the changes between 2007 and 2014. The BLS develops national measures of inflation and wage growth that show how the income of the population, prices, and the value of money change over time. We used the BLS data to project wage growth so that we could determine whether prices were rising at a rate that exceeded the average person's ability to pay. We used inflation data to determine whether price changes represented true increases or just reflected a decrease in the value of a dollar over time. We also looked at BLS data to construct projections by health sector. This process is described in greater detail later in the report. The inflation rate and wage growth rate are presented in Table 1.

TABLE 1. National Measures of Inflation and Wage Growth, in Percent
Service Category Annualized
2007-2014
Annualized
2014-2018 (projected)
Annualized
2007-2018
(projected)
BLS National Inflation Ratea 1.9 0.9 1.6
BLS Wage Growth Rateb 2.4 2.3 2.4
  1. BLS Inflation Data, CPI-All Urban Consumers (Current Series), All items in U.S. city average, all urban consumers, not seasonally adjusted. Retrieved from: https://data.bls.gov/timeseries/CUUR0000SA0.
  2. BLS Wage Data, Employment Cost Index (NAICS), Wages and Salaries for All Civilian Workers in All Industries and Occupations, Index. Retrieved from: https://data.bls.gov/timeseries/CIS1010000000000Q?data_tool=XGtable.

Study Population

We included large private employer-sponsored health plan members, which encompassed employees, spouses, and dependents aged 12-64 years. We excluded enrollees younger than 12 years because of the low prevalence of OUD and enrollees older than 64 years because of Medicare eligibility and the possibility of having secondary insurance. We required at least 10 out of 12 months of enrollment in each calendar year to capture a complete or nearly complete treatment picture for each individual. We excluded plans (and all of their enrollees) that lacked prescription drug claims because of the importance of having complete service records for each enrollee and the need to capture use of MAT. We subdivided our analysis into four plan types and then created a combined all-plan category. The four plan types were health maintenance organizations (HMOs), preferred provider organizations (PPOs), point of service (POS) plans, and a combined group of consumer-directed health plans and high-deductible health plans (CDHPs/HDHPs); (see Table 3 for additional information on plan types). We excluded claims covered by capitated plans that did not include reimbursement information.

Study Periods

We assessed changes in the levels and types of out-of-pocket expenses for patients receiving OUD treatment paid by employer-sponsored health insurance plans during 2007 and 2014, which represent years before and after implementation of major health care legislation. We also used the results of our analysis to project expenses into 2018.

In Table 2, we list the types of out-of-pocket expenses considered, as well as the associated data sources used.

TABLE 2. Types of Health-Related Expenses Considered in This Investigation
Expense Type Description Data Source
Deductibles The amount patients must spend on their own clinical care before their health insurance benefits begin to pay for their treatmenta Kaiser Employee Health Benefit Survey
Premiums The price, typically paid by plan beneficiaries and their employers, to have insurance coverage for a given length of timea Kaiser Employee Health Benefit Survey
Co-payments A set amount beneficiaries pay for each unit of service they receiveda MarketScan CCAE Database
Co-insurance The proportion of the costs of health care that plan beneficiaries must pay after their deductible has been met, subtracting any co-payments MarketScan CCAE Database
Expenditures on services not covered by insurance The cost of treatment for a service that is not covered by an individual's insurance, or costs for an individual that lacks insurance The estimated proportion of plans that provide coverage for "opioid treatment programs" reported in the Brandeis Health Plan Surveys
  1. Centers for Medicare & Medicaid Services. Healthcare.Gov: Glossary. https://www.healthcare.gov/glossary/.

We computed out-of-pocket expenditures for four primary categories of plans: PPOs, POS plans, HMOs, and a combined group of CDHPs/HDHPs.

As shown in Table 3, plans within each of these categories share costs with patients in different ways. For example, HDHPs, as the name suggests, have higher deductible levels. They offer limited coverage until the deductible amount is met, which was at least $1,300 for an individual or $2,600 for a family in 2016.[17] HMOs typically have low or no deductible or cost-sharing for services within their provider networks, but they may require higher premiums and provide negligible coverage for services delivered outside of their provider network. PPOs are a form of insurance that provides lower levels of cost-sharing for services delivered by in-network providers and higher levels of cost-sharing for services delivered outside of the provider network.

TABLE 3. Attributes of Insurance Plan Types Examined in This Investigation
Type of Plan Average Deductible for
Individual, $a
Requires Primary
Care Provider
Needs Referrals Covers Out-of-
Network Care
HMO 917 Yes Yes No
PPO 1,028 No No Yes
HDHP 2,199 Varies Varies Varies
POS 1,737 No No Yes, but costlier
  1. Kaiser Family Foundation, 2016 Employer Health Benefits Survey. From Claxton R, Rae M, Long M, et al. Employer Health Benefits: 2016 Annual Survey. Henry J. Kaiser Family Foundation and Health Research & Educational Trust; 2016. http://files.kff.org/attachment/Report-Employer-Health-Benefits-2016-Annual-Survey.

Ideal 12-Month MAT Treatment Protocol

We defined an ideal 12-month MAT treatment protocol on the basis of recommendations from ASAM,[18] the SAMHSA Center for Substance Abuse Treatment (CSAT),[19] and the report titled SUMMIT: Procedures for Medication-Assisted Treatment of Alcohol or Opioid Dependence in Primary Care produced by RAND Corporation.[20] Both CSAT and ASAM indicated that the maintenance phase should continue indefinitely. However, we conducted an analysis of TEDS data that indicated the median duration of treatment for individuals successfully completing MAT was less than 1 year,[21] so we estimated the expenditures on the basis of a year of treatment.

Both CSAT and ASAM guidelines indicated the potentially useful role that psychotherapy could offer in conjunction with opioid agonist treatment, though ASAM highlighted that evidence is mixed for its effectiveness relative to treatment by medication alone. In particular, cognitive behavioral therapy has been found to be useful as an adjunct to medication. According to the Mayo Clinic,[22] cognitive behavioral therapy typically involves 10-20 sessions; therefore, we assumed that 15 sessions were typical for a patient receiving MAT.

We determined that an ideal MAT treatment protocol for a 12-month period of OUD treatment should include the following:

  1. Office-based induction with daily visits to assess efficacy of dosing (which is 3 days according to CSAT guidelines, though the SUMMIT guidelines suggest it could be 4 days).

  2. Transitions to weekly visits after stable dosing is achieved.

  3. Office visits to the provider continuing at least monthly during the maintenance phase after the patient becomes stable for 1 month.

For our calculations for the cost of an ideal MAT treatment protocol for a 12-month period of OUD treatment, we included the amount paid for the following:

  • Three daily physician office visits.

  • Four weekly physician office visits.

  • Eleven monthly visits to physician offices, for a total of 18 office visits.

  • Twelve months of buprenorphine/naloxone prescription fills for 28-30 days.

  • Fifteen visits to a behavioral health provider for psychotherapy (i.e., cognitive behavioral therapy).[23]

All Services Considered

In addition to the services included in the MAT treatment protocol, we also looked at costs for other OUD-related services, including inpatient stays, intensive outpatient treatment, detoxification services, and emergency department visits. These services are individualized and therefore are not included in the cost of an ideal treatment protocol. However, their high associated costs make them a relevant consideration when analyzing treatment-related expenses. The total list of services included in the analysis is in Table 4.

TABLE 4. OUD Treatment Service Category Definitions
Service Category Definition
Inpatient, including detoxifications Inpatient stays in hospitals, including those involving patients detoxifying from substances and not receiving further treatment
Outpatient detoxification Detoxification services often delivered as residential, intensive outpatient, or partial hospitalization services
Residential treatment Short-term and long-term residential treatment services
Intensive outpatient or partial hospitalization services Intensive outpatient (e.g., day programs) or partial hospitalization (<24 hour) services
Treat-and-release ED visits ED visits that resulted in a discharge (i.e., did not end in an inpatient admission)
Outpatient visit Evaluation, management, and other outpatient services not elsewhere classified
Psychotherapy Psychotherapy delivered in an outpatient setting
Buprenorphine/naloxone prescription Buprenorphine prescription drug fill of 28-30 days

Health-Related Expenses

Amount Paid Per Service by the Insurer and the Beneficiary

We identified the amount paid for each of these services and for the MAT treatment protocol. We calculated the median amount paid using the claims data for each service overall and separately for each plan type. We excluded claims where the total amount paid was less than or equal to zero because we were only interested in the amount paid for a claim, not claims where the provider was not compensated or claims where the data may have been inaccurate. These amounts included the total amount paid by the insurer and the insured.

Deductibles and Premiums

We described deductibles and premiums reported in the KEHB for the four most common categories of plans (HMO, PPO, POS, CDHP/HDHP). This step involved summarizing the data on the premium and deductible amounts for each plan type reported in the KEHB for calendar years 2007 and 2014 to understand trends in insurance expenses, specifically in deductibles and premiums, over the study period.

In this section of the analysis, we also presented data from multiple sources regarding inflation, wage growth between 2007 and 2014, and projected growth in 2018. This information can be used to compare rates of change so that we can further understand whether there were real increases, as opposed to nominal changes. This process is especially important when looking at the wage growth data, because it allows us to understand how the change in health expenditures affect patients relative to changes in their expected earnings. For example, if expenditure growth exceeds wage growth, then the disposable income of individuals with OUD decreases over time as the proportion of their income devoted to medical expenditures increases.

Co-payment

In addition to the above, we identified the co-payment for services in each category listed in Table 4. For this stage, we used the claims data. When we calculated the average co-payment for a service in each category, we separately considered two things. First, to determine the impact of co-payments on the cost of the MAT treatment protocol, we used the mean co-payment per unit of service used by plan type. This was a weighted average that considered services where a co-payment was charged and services where a co-payment was not charged. The result reflected the cost of care from co-payments experienced by individuals using services, on average. Second, to determine the customary level of co-payments per service by plan type, we calculated the median co-payment for services for which a co-payment was charged.

As a supplementary analysis, we calculated to the proportion of services with a co-payment charged in each of the 2 years for which we had data. This allowed us to understand whether there was a change in the proportion of services with co-payments across points in time.

Co-insurance Amount Per Service

In addition to deductibles, co-payments, and premiums, co-insurance may represent an out-of-pocket cost to individuals receiving MAT. As with co-payments, we identified the co-insurance rate for services in each category listed in Table 4 using the MarketScan CCAE. Our methodology for calculating the co-insurance rate differed slightly from others described above.

Co-insurance, unlike the other costs to beneficiaries, is a proportion of the cost of a service after deductible and co-payments are excluded. Therefore, we calculated it by dividing the total co-insurance amount for a unit of service by the total price of that service after subtracting deductibles and co-payments.

As with co-payments, we calculated the mean co-insurance per unit of service (which is a weighted average and includes zeros), the proportion of services for which co-insurance was charged, and the median co-insurance rate for services for which any co-insurance was charged. This allowed us to explore trends in co-insurance levels, as well as the change the frequency of use and impact on clients with OUD.

Costs to the Uninsured and Rate of Out-of-Network Service Use

Individuals with insurance may be enrolled in plans that do not provide coverage for all services. Therefore, we attempted to quantify the costs of treatment for services not covered by insurance. Moreover, recent research has shown that a significant number of individuals receiving services from psychiatrists, relative to other health care providers, have had to receive this care out-of-network.[24] That same research indicates that the amount paid to providers is greater when a service is out-of-network than in-network. To evaluate this, we calculated rates of out-of-network service use in each year. We also calculated the amount paid for services by the uninsured by assuming that the uninsured would pay a rate comparable to the rate charged for out-of-network services, because these rates are not pre-negotiated by an insurance plan.

Additionally, we used the out-of-network price to calculate the cost to patients for specialty OUD treatment that insurance plans may not cover. This was necessary because insured individuals without coverage for specific services may be required to pay completely out-of-pocket for these services. We used the rates for the years reported that are closest to the years analyzed in our study from results of the Brandeis health insurance plan survey reported by Reif and colleagues.[25]

Projection to Future Years

To project costs in 2018, we used results of our analysis of the 2014 MarketScan data. We only created projections for data points for which we had sufficient data, defined as at least 10 services used by the study population during the year for which a claim was submitted to an insurer. We adjusted for inflation by using relevant BLS Consumer Price Index (CPI) categories. The category used for each service is presented in Table 5.

To develop the trend factors, available months of data were used from the 2014 midpoint (July 1, 2014) to the last available month (September 1, 2017). To create the factor to the midpoint of 2018 (July 1, 2018), a 3-month moving average was applied for the remaining time period. The mean and median values were projected as appropriate. The Health Insurance CPI factor[26] was the only factor that was not seasonally adjusted, because seasonal adjustment was not available. For factors where both seasonally adjusted and not seasonally adjusted estimates were available, the differences between the two were small.

TABLE 5. Inflation Factors Used to Calculate Projections
Service Category Inflation Factor Used
Inpatient, including detoxification Inpatient hospital servicesa
Outpatient detoxification Outpatient hospital servicesb
Residential Nursing homes and adult day servicesc
Intensive outpatient or partial hospitalization service Outpatient hospital servicesb
Treat-and-release ED visit Outpatient hospital servicesb
Outpatient visit for opioid disorder Physician servicesd
Psychotherapy Physician servicesd
Buprenorphine/naloxone prescription Prescription drugse
  1. BLS Inflation Data, CPI-All Urban Consumers (Current Series). Inpatient hospital services in U.S. city average, all urban consumers, seasonally adjusted. Retrieved from: https://beta.bls.gov/dataViewer/view/timeseries/CUSR0000SS5702.
  2. BLS Inflation Data, Outpatient hospital services in U.S. city average, all urban consumers, seasonally adjusted. Retrieved from: https://beta.bls.gov/dataViewer/view/timeseries/CUSR0000SS5703.
  3. BLS Inflation Data, CPI-All Urban Consumers (Current Series). Nursing homes and adult day services in U.S. city average, all urban consumers, seasonally adjusted. Retrieved from: https://beta.bls.gov/dataViewer/view/timeseries/CUSR0000SEMD02.
  4. BLS Inflation Data, Physicians' services in U.S. city average, all urban consumers, seasonally adjusted. Retrieved from: https://beta.bls.gov/dataViewer/view/timeseries/CUSR0000SEMC01.
  5. BLS Inflation Data, Prescription drugs in U.S. city average, all urban consumers, seasonally adjusted. Retrieved from: https://beta.bls.gov/dataViewer/view/timeseries/CUSR0000SEMF01.

 

RESULTS

Sample Characteristics

We report health plan enrollment statistics and sample characteristics in this section. There was a shift in the proportion of the population according to plan type (Figure 1). Compared with 2007, in 2014 a greater percentage of people were enrolled in HDHPs (from 1.9 percent to 17.7 percent), with a corresponding decrease in the percentage enrolled in HMOs and POS plans.

FIGURE 1. Total Number of Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, by Plan Type, 2004 and 2014
2007 2014
FIGURE 1, Pie Chart, Year 2007: CDHP and HDHP 2%, HMO 21%, POS 16%, PPO 61%. There was a shift in the proportion of the population according to plan type.  Compared with 2007, in 2014 a greater percentage of people were enrolled in high-deductible plans (from 1.9% to 17.7%), with a corresponding decrease in the percentage enrolled in HMOs and POS plans. FIGURE 1, Pie Chart, Year 2014: CDHP and HDHP 18%, HMO 9%, POS 8%, PPO 65%. There was a shift in the proportion of the population according to plan type.  Compared with 2007, in 2014 a greater percentage of people were enrolled in high-deductible plans (from 1.9% to 17.7%), with a corresponding decrease in the percentage enrolled in HMOs and POS plans.
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.

Table 6A and Table 6B provide descriptive information about the eligible study samples for each of the two periods, overall and by plan type. In both years, the study sample was disproportionately male (56 percent in 2007, 59 percent in 2014). There do not appear to be significant differences in the plan type by the individual's sex, with each plan type being between 39 percent and 47 percent female in both study periods. There does not appear to be much evidence of discrimination in plan type by age, although the mean age is lowest in CDHPs and HDHPs in both periods. Individuals in PPO plans were disproportionately in the 45-64 age group in the 2007 sample. This age group accounted for 41 percent of the individuals in PPOs in 2007 (as opposed to 38 percent across all plan types). However, in 2014 the number of individuals aged 45-64 in PPOs was equal to the average across all plans in 2014, with 31 percent in each.

There was a large increase in the proportion of adults aged 19-26 enrolled as a dependent child/other on their insurance plan that both had OUD and accessed services in 2014 relative to 2007 (increasing from 12.0 percent to 27.9 percent).

TABLE 6A. Characteristics of Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, Total and by Plan Type, 2007
Characteristics Total
N
Total
%
HMO
N
HMO
%
POS
N
POS
%
PPO
N
PPO
%
CDHP/
HDHP
N
CDHP/
HDHP
%
Totals 9,095   100.0 1,858 100.0 1,494 100.0 5,568 100.0 175 100.0
Sex
Male 5,109 56.2 1,064 57.3 838 56.1 3,114 55.9 93 53.1
Female 3,986 43.8 794 42.7 656 43.9 2,454 44.1 82 46.9
Age Group
12-17 414 4.6 82 4.4 63 4.2 256 4.6 13 7.4
18-44 5,209 57.3 1,160 62.4 921 61.6 3,023 54.3 105 60.0
45-64 3,472 38.2 616 33.2 510 34.1 2,289 41.1 57 32.6
Among 19-26
19-26 (all covered) 1,607 17.7 310 16.7 282 18.9 988 17.7 27 15.4
19-26 (dependent child/other) 1,089 12.0 214 11.5 157 10.5 709 12.7 9 5.1
Relationship to Insured
Employee 4,126 45.4 820 44.1 729 48.8 2,500 44.9 77 44.0
Spouse 3,196 35.1 677 36.4 501 33.5 1,946 34.9 72 41.1
Child/Other 1,773 19.5 361 19.4 264 17.7 1,122 20.2 26 14.9
Region
North East 1,271 14.0 240 12.9 394 26.4 620 11.1 17 9.7
North Central 2,478 27.2 452 24.3 245 16.4 1,747 31.4 34 19.4
South 3,429 37.7 592 31.9 647 43.3 2,114 38.0 76 43.4
West 1,864 20.5 557 30.0 198 13.3 1,061 19.1 48 27.4
Unknown 53 0.6 17 0.9 NSD NSD 26 0.5 NSD NSD
SOURCE: Truven Health MarketScan CCAE Database, 2007.

 

TABLE 6B. Characteristics of Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, Total and by Plan Type, 2014
Characteristics Total
N
Total
%
HMO
N
HMO
%
POS
N
POS
%
PPO
N
PPO
%
CDHP/
HDHP
N
CDHP/
HDHP
%
Totals 42,129 100.0 3,660 100.0 3,428 100.0 27,595 100.0 7,446 100.0
Sex
Male 24,980 59.3 2,229 60.9 1,951 56.9 16,369 59.3 4,431 59.5
Female 17,149 40.7 1,431 39.1 1,477 0.4 11,226 40.7 3,015 40.5
Age Group
12-17 783 1.9 76 2.1 59 1.7 468 1.7 180 2.4
18-44 8,208 67.0 2,432 66.4 2,168 63.2 18,477 67.0 5,131 68.9
45-64 13,138 31.2 1,152 31.5 1,201 35.0 8,650 31.3 2,135 28.7
Among 19-26
19-26 (all covered) 13,093 31.1 1,206 33.0 934 27.2 8,526 30.9 2,427 32.6
19-26 (dependent child/other) 11,744 27.9 1,134 31.0 821 23.9 7,618 27.6 2,171 29.2
Relationship to Insured
Employee 16,540 39.3 1,332 36.4 1,488 43.4 10,974 39.8 2,746 36.9
Spouse 12,172 28.9 1,030 28.1 978 28.5 7,965 28.9 2,199 29.5
Child/Other 13,417 31.8 1,298 35.5 962 28.1 8,656 31.4 2,501 33.6
Region
North East 10,223 24.3 690 18.9 1,136 33.1 7,161 26.0 1,236 16.6
North Central 7,360 17.5 1,207 33.0 293 8.5 4,417 16.0 1,443 19.4
South 17,392 41.3 850 23.2 1,403 0.4 11,591 42.0 3,548 47.6
West 6,931 16.5 851 23.3 596 17.4 4,353 15.8 1,131 15.2
Unknown 223 0.5 62 1.7 --- 0.0 73 0.3 88 1.2
SOURCE: Truven Health MarketScan CCAE Database, 2014.

Health-Related Expenses

Amount Paid Per Service by the Insurer and the Beneficiary

Table 7A highlights the change in payments for the services considered across the study period and projected into 2018. Results indicate that the fastest rate of growth was the amount paid for residential treatment, with an average growth rate of 16.3 percent per year from 2007 through 2014.

The slowest rate of growth was observed for psychotherapy, which experienced a decline in payments at the median.

This result likely is explained by a change in Current Procedural Terminology (CPT®) codes,[27] which decreased the amount of reimbursement per minute of a psychotherapy visit by decoupling the evaluation and management component from the psychotherapy component. The slowest rate of growth in services for which the CPT codes did not change was in the amount paid for outpatient detoxification. In general, the results indicate an increase in the median amount paid for an OUD service that exceeds the inflation rate.

TABLE 7A. Average Payment per Unit of Service in 2007, 2014, and 2018 (projected) for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, Annualized Percent Change Between 2007 and 2014, and Projected Change Through 2018
Service Category 2007, $ 2014, $ Projected
2018, $
Annualized
% Change
2007-2014
Annualized
% Change
2007-2018
Inpatient, including detoxification, per day 896 1,200 1,415 4.3 4.2
Outpatient detoxification, per day 250 275 323 1.4 2.4
Residential, per day 156 450 510 16.3 11.4
Intensive outpatient or partial hospitalization, per day 180 345 406 9.7 7.7
Treat-and-release ED visits (all visits that never become inpatient stays) 328 756 889 12.7 9.5
Outpatient office visit 75 90 95 2.7 2.2
Psychotherapy or behavioral therapy office visit 79 67 71 -2.4 -1.0
Buprenorphine or buprenorphine naloxone prescription fill 283 355 417 3.3 3.5
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.

Figure 2A shows that the amount paid for the 12-month MAT treatment protocol grew at a rate slightly faster than the rate of inflation. The amount paid for the protocol grew an average of 2.2 percent per year across all plans between 2007 and 2014. Moreover, the growth of the total was much slower than the rate of growth in HMOs and POS plans. This is because in the second period the sample included a greater percentage of individuals enrolled in HDHP and PPO plans, which had lower amounts paid at baseline than the other plan types. These plans had lower unit payments for services than the other insurance plan types; therefore, as their share of the study sample increased, it reduced the rate of growth in the median unit payments for these services.

FIGURE 2A. Change in Total Payments During the Study Period for the Receipt of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018 (projected)
FIGURE 2A, Bar Chart. This shows that the amount paid for the 12-month MAT protocol grew at a rate slightly faster than the rate of inflation.  The amount paid for the protocol grew an average of 2.2% per year across all plans between 2007 and 2014.  Moreover, the growth of the total was much slower than the rate of growth in HMOs and POS plans.
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.
NOTE: We approximate an ideal treatment protocol containing three intake office visits, with buprenorphine administration (note the price of buprenorphine administration is not included in the ideal basket due to a lack of sufficient data on this measure for certain plan types), 4 weekly office visits, 12 months of buprenorphine medication, 11 monthly office visits, and 15 psychotherapy visits.
  1. 2018 is projected.

Another potential confounder was the change in CPT codes for psychotherapy. To assess the effects of this coding change, we conducted a sensitivity analysis restricted to psychotherapy provided by psychologists and social workers. These individuals provide most of psychotherapy to the MarketScan population and were not affected by the change in billing codes, which did not change billing for non-physician clinicians. The result was that the growth in the amount paid for the protocol grew at a rate slightly above the rate of inflation.

FIGURE 2B. Annualized Percent Change in Payments During the Study Period for the Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007-2014 and 2007-2018 (projected)
FIGURE 2B, Bar Chart: Shows that the annualized percent change in payments during the study period (2007-2014) was greatest in HMO and POS plans, 3.8%. This was greater than wage increases, 2.4%, or inflation, 1.9%. For the projected study period (2007-2018) HMO and POS plans have the greatest annualized percent change in payments, 3.5% and 3.4% which continues to increase faster than wages, 2.4%, and inflation, 1.6%.
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.
NOTE: We approximate an ideal treatment protocol containing 3 intake office visits, with buprenorphine administration (note the price of buprenorphine administration is not included in the ideal basket due to a lack of sufficient data on this measure for certain plan types), 4 weekly office visits, 12 months of buprenorphine medication, 11 monthly office visits, and 15 psychotherapy visits.

Between 2007 and 2014, there was annualized growth in the combined insurance and out-of-pocket payments for the three most common services outside of the MAT treatment protocol, across all insurance plan types (Table 7B). The largest growth in the amount paid for inpatient treatment was observed for PPOs, with a rate of 5.1 percent during that period; the least growth was observed for HMOs, with a rate of 0.9 percent. The largest growth in the amount paid for intensive outpatient treatment was observed within PPOs, with a rate of 10.8 percent during that period; the least growth was observed for HMOs, with a rate of 3.8 percent. The largest growth in the amount paid for treat-and-release emergency department (ED) treatment was observed within PPOs, with a rate of 15.1 percent during that period; the least growth was observed for POS plans, with a rate of 7.5 percent. This same trend is projected to continue between 2014 and 2018, with data indicating an increase in total payments for the three services across this time period.

TABLE 7B. Change in Total Payments During the Study Period for the Receipt of Services Outside of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018 (projected)
Plan Type Service Category Median
2007, $
Median
2014, $
Median
2018, $
(projected)
Annualized
% Change
2007-2014
Annualized
% Change
2007-2018
(projected)
HMO Inpatient, including detoxification, per day 978 1043 1230 0.9 2.1
HMO Intensive outpatient or partial hospitalization per day 200 260 306 3.8 3.9
HMO Treat-and-release ED visits (all visits that never become inpatient stays) 445 745 876 7.6 6.3
PPO Inpatient, including detoxification, per day 850 1205 1421 5.1 4.8
PPO Intensive outpatient or partial hospitalization per day 172 354 416 10.8 8.3
PPO Treat-and-release ED visits (all visits that never become inpatient stays) 289 772 908 15.1 11.0
POS Inpatient, including detoxification, per day 922 1162 1370 3.4 3.7
POS Intensive outpatient or partial hospitalization per day 175 285 335 7.2 6.1
POS Treat-and-release ED visits (all visits that never become inpatient stays) 404 672 790 7.5 6.3
CDHP/HDHP Inpatient, including detoxification, per day 948 1302 1535 4.6 4.5
CDHP/HDHP Intensive outpatient or partial hospitalization per day 256 383 450 5.9 5.3
CDHP/HDHP Treat-and-release ED visits (all visits that never become inpatient stays) 280 729 857 14.7 10.7
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.

Deductibles and Premiums

Table 8A reveals how deductibles and premiums changed during the study period. Between 2007 and 2014, annualized deductibles increased for all types of health plans at a rate faster than inflation. The greatest increase in both percentage terms and in total dollar value occurred in HMOs. Premiums rose faster than inflation during the study period, as did the payments for insurance to the employer and to the beneficiary. PPOs had the slowest rate of premium growth, and HMOs had the fastest rate of growth. The highest total deductibles were in CDHPs/HDHPs, and PPOs had the lowest. However, even though the PPO had the most generous plan in terms of deductibles for individuals on single-person coverage, it still required surmounting a deductible of $843 on average, which was an increase of 83 percent from 2007.

TABLE 8A. Average Deductibles and Premiums for Employer-Sponsored Health Insurance from the 2007 and 2014 KEHB
Plan Type All Regions 2007,
Single, $
2007,
Family, $
2014,
Single, $
2014,
Family, $
Annual Race
of Change
2007-2014,
Single, %
Annual Race
of Change
2007-2014,
Family, %
HMO Deductible 401 759 1,032 2,328 14.5 17.4
HMO Premium 4,299 11,879 6,223 17,383 5.4 5.6
HMO Individual cost 711 3,311 1,182 5,254 7.5 6.8
HMO Employer contribution 3,588 8,568 5,041 12,129 5.0 5.1
POS Deductible 621 1,359 1,215 2,470 10.1 8.9
POS Premium 4,337 11,588 6,166 16,037 5.2 4.8
POS Individual cost 628 3,659 984 4,849 6.6 4.1
POS Employer contribution 3,709 7,929 5,182 11,188 4.9 5.0
PPO Deductible 461 1,040 843 1,954 9.0 9.4
PPO Premium 4,638 12,443 6,217 17,333 4.3 4.8
PPO Individual cost 717 3,236 1,134 4,877 6.8 6.0
PPO Employer Contribution 3,921 9,207 5,083 12,456 3.8 4.4
HDHP* Deductible 1,729 3,596 2,215 4,522 3.6 3.3
HDHP* Premium 3,869 10,693 5,299 15,401 4.6 5.4
HDHP* Individual cost 522 2,856 $905 4,385 8.2 6.3
HCHP* Employer contribution 3,347 7,837 4,394 11,016 4.0 5.0
SOURCES: Henry J. Kaiser Family Foundation and Health Research & Educational Trust (2007). Employer Health Benefits 2007 Annual Survey. Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Retrieved from: https://kaiserfamilyfoundation.files.wordpress.com/2013/04/76723.pdf.
Henry J. Kaiser Family Foundation and Health Research & Educational Trust (2014). Employer Health Benefits 2014 Annual Survey. Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Retrieved from: https://kaiserfamilyfoundation.files.wordpress.com/2014/09/8625-employer-health-benefits-2014-annual-survey6.pdf.
* HDHP with savings option.

Given that the deductibles were always below the cost of treatment for the MAT treatment protocol, as shown in Table 8B, we could add the deductible to the individual payments for insurance to get an estimate of the annual expenditure for the patient before any of their insurance benefits become effective. From this, we found that for an individual with OUD receiving an appropriate treatment protocol, the payments for the premium and deductible were greatest for an individual with the HDHP plan. However, the rate of growth for premiums and deductibles combined was lowest for HDHP plans. Conversely, PPOs had the lowest combined payments for the employee's portion of premium and deductible in 2014. This was not the case in 2007, when HMOs had a lower associated amount paid but experienced the fastest increase during the study period.

TABLE 8B. Combined Average Deductibles and Premiums for Employer-Sponsored Health Insurance from the 2007 and 2014 KEHB
Plan Type Unit of Coverage 2007, $ 2014, $ Annualized Rate
of Change
2007-2014
HMO Individual 1,112 2,214 10.3
HMO Family 4,070 7,582 9.3
POS Individual 1,249 2,199 8.4
POS Family 5,018 7,319 5.5
PPO Individual 1,178 1,977 7.7
PPO Family 4,276 6,831 6.9
HDHP Individual 2,251 3,120 4.8
HDHP Family 6,452 8,907 4.7
Total Individual N/A 3,296 N/A
Total Family N/A N/A N/A
SOURCES: Henry J. Kaiser Family Foundation and Health Research & Educational Trust (2007). Employer Health Benefits 2007 Annual Survey. Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Retrieved from: https://kaiserfamilyfoundation.files.wordpress.com/2013/04/76723.pdf.
Henry J. Kaiser Family Foundation and Health Research & Educational Trust (2014). Employer Health Benefits 2014 Annual Survey. Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Retrieved from: https://kaiserfamilyfoundation.files.wordpress.com/2014/09/8625-employer-health-benefits-2014-annual-survey6.pdf.

Co-payment

Table 9 and Table 10, and Figure 3A and Figure 3B, indicate how co-payments changed over the study period. For our sample, the mean co-pay for the 12-month protocol of services declined from $747 in 2007 to $658 in 2014. We projected that it will rise to $728 in 2018. The change between 2007 and 2014 primarily was due to the decrease in the average co-payment for buprenorphine prescription fills and outpatient visits. However, because of the increase in deductibles, this change did not indicate a decrease in cost-sharing. In general, co-payments did not affect the results until medical expenses exceeded the deductible. It is likely that with the increased utilization of CDHP/HDHP plan types and the increase in deductibles in all plans, looking at trends in co-payments alone understates the shift of expenses from insurers to patients. This is made obvious by the fact that PPOs had the lowest average deductibles but the largest increases in co-payments during the study period. With that said, when we restricted our analysis to visits that included a co-payment, we found that the median co-payment for a service in which a co-payment was charged decreased dramatically for detoxification and residential treatment services. Additionally, among the services that comprise the ideal MAT treatment protocol, only the amount paid for a psychotherapy co-pay increased (from $17 to $20). Therefore, we did not find evidence in our analysis that changes in co-payments represented a new or increasing barrier to OUD treatment during the study period.

Between 2007 and 2014, there were variable rates of change in the co-payments of the four most common services outside of the bundle of services included in MAT, across all insurance plan types. It should be noted that there were insufficient data for some services, which could affect overall results. The greatest growth in the amount paid for inpatient treatment was observed within CDHPs/HDHPs, with a rate of 18.5 percent during that period; the least co-payment growth was observed for POS plans, which had a decline of 14.3 percent. There was a decline in the co-payment of intensive outpatient treatment across all plan types. The slowest decline was observed within PPOs, with a rate of -7.2 percent during that period; the fastest decline was observed for CDHPs/HDHPs, with a rate of -25.4 percent. The greatest growth in the amount paid for treat-and-release emergency department treatment was observed within PPOs, with a rate of 12.1 percent during that period; the least growth was observed for POS plans, with a rate of 4.0 percent. The greatest growth in the amount paid for co-payments for outpatient detoxification services were observed in PPOs, with an annual increase of 0.1 percent; the least growth was observed for POSs, with a rate of -0.3 percent. In contrast, we projected a growth in the amount paid for co-payments between 2014 and 2018 for all service types considered.

FIGURE 3A. Mean Co-payment for the Receipt of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018 (projected)
FIGURE 3A, Bar Chart: This figure indicates how copayments changed over the study period.  For our sample, the mean copay for the 12-month protocol of services declined from $747 in 2007 to $658 in 2014.  We projected that it will rise to $728 in 2018.
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.
* 2018 is projected.

 

FIGURE 3B. Annualized Percent Change in the Mean Co-payment for the Receipt of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007-2014 and 2007-2018 (projected)
FIGURE 3B, Bar Chart: This figure indicates how copayments changed over the study period.  For our sample, the mean copay for the 12-month protocol of services declined 3.5% for HMO plans and 3.6% for POS plans.  We projected that it will decrease by 1.4% for HMO and 1.3% for POS plans.
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.

 

TABLE 9. Co-payments for the Receipt of Common OUD Treatments for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007, 2014, and 2018 (projected)
Service Category % of Visits
with Co-pay,
2007
% of Visits
with Co-pay,
2014
% of Visits
with Co-pay,
2018
Mean Co-pay
for All Visits,
2007, $
Mean Co-pay
for All Visits,
2014, $
Mean Co-pay
for All Visits,
2018, $
Median Co-pay When
Co-pay Was Charged,
2007, $
Median Co-pay When
Co-pay Was Charged,
2014, $
Median Co-pay When
Co-pay Was Charged,
2018, $
Inpatient, including detoxification, per day 30 19 N/A 28 18 21 50 50 59
Outpatient detoxification, per day 12 23 N/A 10 11 13 39 20 24
Residential, per day 8 9 N/A 6 5 6 50 22 26
Intensive outpatient or partial hospitalization, per day 18 10 N/A 12 7 8 20 20 24
Treat-and-release ED visits (all visits that never become inpatient stays) 34 37 N/A 24 39 45 52 80 94
Outpatient office visit 49 44 N/A 13 11 12 20 20 21
Psychotherapy or behavioral therapy office visit 35 40 N/A 8 9 9 17 20 21
Buprenorphine or buprenorphine naloxone prescription fill 88 78 N/A 33 27 31 34 25 29
SOURCE: Truven Health MarketScan CCAE Database, 2007 and 2014.

 

TABLE 10. Mean Co-payment for Services for the Receipt of Common OUD Treatments Outside of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, by Plan Type, 2007, 2014, and 2018 (projected)
Plan Type Service Category 2007, $ 2014, $ 2018, $
(projected)
Annualized
Change, %
2007-2014
Annualized
Change, %
2007-2018
(projected)
HMO Inpatient, including detoxification, per day 33.0 35.6 42.0 1.1 2.2
HMO Intensive outpatient or partial hospitalization, per day 18.1 10.2 12.0 -7.8 -3.6
HMO Treat-and-release ED visits (all visits that never become inpatient stays) 33.7 64.2 75.4 9.6 7.6
PPO Inpatient, including detoxification, per day 24.9 14.7 17.4 -7.2 -3.2
PPO Intensive outpatient or partial hospitalization, per day 6.6 3.9 4.6 -7.2 -3.2
PPO Treat-and-release ED visits (all visits that never become inpatient stays) 19.7 44.0 51.7 12.1 9.2
POS Inpatient, including detoxification, per day 38.6 13.1 15.5 -14.3 -8.0
POS Intensive outpatient or partial hospitalization, per day 13.2 2.5 2.9 -21.3 -12.8
POS Treat-and-release ED visits (all visits that never become inpatient stays) 32.1 42.1 49.4 4.0 4.0
CDHP/HDHP Inpatient, including detoxification, per day 7.2 23.6 27.9 18.5 13.1
CDHP/HDHP Intensive outpatient or partial hospitalization, per day 154.9 19.9 23.4 -25.4 -15.8
CDHP/HDHP Treat-and-release ED visits (all visits that never become inpatient stays) NSD 4.4 5.2 NSD NSD
SOURCE: Truven Health MarketScan CCAE Database, 2007 and 2014.

Co-insurance Amount Per Service

We observed several interesting relationships in our data on co-insurance, shown in Table 11 and Table 12. First, the proportion of visits with any co-insurance billed increased for all services except intensive outpatient care and outpatient detoxification. Second, the median co-insurance percentage for services with any co-insurance increased or remained the same for all services except for psychotherapy, for which it was lowered. Third, the mean amount of co-insurance for an ideal protocol of services increased by 0.6 percentage points in 2014, or 13.0 percent relative to 2007, even though the mean for all insurance plan types except HMOs decreased during that period. This was a result of the increased use of CDHP/HDHP and PPO plan types, which had the highest mean co-insurance during the study period, and was not a reflection of the fact that these plans began instituting higher co-insurance levels on the average service considered. As with co-payment data, these results should be interpreted with caution. Higher deductibles may mitigate the effect of co-insurance on the mean service, because more services will be provided under the deductible and thus may not be subject to co-insurance.

TABLE 11. Co-insurance Rates for the Receipt of Common OUD Treatments for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007 and 2014
Service Category % of Visits
With Co-insurance,
2007
% of Visits
With Co-insurance,
2014
Mean for
All Visits,
2007, %
Mean for
All Visits,
2014, %
Median Among Visits
With Co-insurance,
2007, %
Median Among Visits
With Co-insurance,
2014, %
Inpatient, including detoxification, per day 41.3 52.4 5 7 10 10
Outpatient detoxification per day 43.0 33.2 12 8 20 20
Residential per day 26.5 30.3 3 8 10 20
Intensive outpatient or partial hospitalization per day 32.1 30.0 6 7 10 20
Treat-and-release ED visits (all visits that never become inpatient stays) 23.5 31.8 4 6 15 20
Outpatient office visit 24.8 26.9 6 6 20 20
Psychotherapy or behavioral therapy office visit 19.2 23.5 5 6 29 20
Buprenorphine or buprenorphine naloxone prescription fill 12.4 16.2 2 4 11 20
SOURCE: Truven Health MarketScan CCAE Database, 2007 and 2014.

As shown in Table 12, between 2007 and 2014 there was growth in the mean co-insurance for the three most common services outside of the MAT treatment protocol. This growth occurred for all insurance plan types except for intensive outpatient services for PPOs and inpatient services for CDHPs/HDHPs. It should be noted that there was insufficient data for some services, which could affect overall results. The greatest growth of inpatient treatment was observed within HMOs, with a rate of 8.3 percent during that period; the least growth was observed for CDHPs/HDHPs, with a rate of -1.4 percent. The greatest growth of intensive outpatient treatment was observed within HMOs, with an annualized growth rate of 24.5 percent during that period; the least growth was observed for PPOs, with a rate of -1.6 percent. The greatest growth of treat-and-release emergency department treatment was observed within HMOs, with a rate of 32.2 percent during that period; the least growth was observed for PPOs, with a rate of 0.1 percent.

TABLE 12. Mean Co-insurance Rates for the Receipt of Common OUD Treatments Outside of an Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, by Plan Type, 2007 and 2014
Plan Type Service Category Mean
2007, %
Mean
2014, %
Absolute Difference
2007-2014,
Percentage Point
Aggregate Change
2007-2014, %
Annualized Change
2007-2014, %
HMO Inpatient, including detoxification, per day 1.2 2.2 0.9 74.4 8.3
HMO Intensive outpatient or partial hospitalization per day 0.4 1.8 1.4 362.7 24.5
HMO Treat-and-release ED visits (all visits that never become inpatient stays) 0.2 1.1 1.0 606.9 32.2
PPO Inpatient, including detoxification, per day 6.7 8.3 1.6 24.5 3.2
PPO Intensive outpatient or partial hospitalization per day 7.7 6.9 -0.8 -10.4 -1.6
PPO Treat-and-release ED visits (all visits that never become inpatient stays) 5.6 5.6 0 0.4 0.1
POS Inpatient, including detoxification, per day 4.3 5.6 1.3 30.5 3.9
POS Intensive outpatient or partial hospitalization per day 2.4 4.1 1.7 69.1 7.8
POS Treat-and-release ED visits (all visits that never become inpatient stays) 2.3 4.1 1.8 79.0 8.7
CDHP/HDHP Inpatient, including detoxification, per day 8.4 7.6 -0.8 -9.2 -1.4
CDHP/HDHP Intensive outpatient or partial hospitalization per day 3.2 8.9 5.6 174.6 15.5
CDHP/HDHP Treat-and-release ED visits (all visits that never become inpatient stays) NSD 9.4 NSD NSD NSD
SOURCE: Truven Health MarketScan CCAE Database, 2007 and 2014.

Coverage Changes Between 2007 and 2014

To determine the way coverage for OUD services changed between 2007 and 2014, we considered findings from a study by Horgan and colleagues (2016) using the Brandeis Health Insurance Survey (see Figure 4). The study showed that by 2010, more than 99.6 percent of health plans covered inpatient detoxification and inpatient hospitalization for substance abuse, and 100 percent covered outpatient counseling and therapy. However, only between 86 percent and 84 percent of health plans covered residential rehabilitation, which represented a decline in the availability of this service. Moreover, the study found that 100 percent of health plans covered treatment for buprenorphine pharmacy in 2010. For our analysis, we considered the 2003 data from the Horgan et al. study to represent coverage prior to parity (2007), and data from 2010 and later to approximate coverage after parity.

FIGURE 4. Proportion of Insurance Plans Covering Common SUD Services, 2003 and 2010
FIGURE 4, Bar Chart: The study showed that by 2010, more than 99.6% of health plans covered inpatient detoxification and inpatient hospitalization for substance abuse, and 100% covered outpatient counseling and therapy.  However, only between 86% and 84% of health plans covered residential rehabilitation, which represented a decline in the availability of this service.  Moreover, the study found that 100% of health plans covered treatment for buprenorphine pharmacy in 2010.  For our analysis, we considered the 2003 data from the Horgan et al. study to represent coverage prior to parity (2007), and data from 2010 and later to approximate coverage after parity.
SOURCE: Horgan CM, Stewart MT, Reif S, et al. Behavioral health services in the changing landscape of private health plans. Psychiatric Services. 2016; 67(6): 622-629.

Costs to the Uninsured and Rate of Out-of-Network Service Use

In terms of out-of-network service use within the ideal protocol of services, we found a large increase in use of out-of-network psychotherapy, as shown in Table 13 and Table 14. In 2007, only 15.3 percent of psychotherapy was delivered out-of-network, and this increased to 25.5 percent in 2014. This increase was noted across all plan types, with the largest increase in the share of out-of-network office visits occurring within CDHP/HDHP and PPO plan types. There was a decrease in the proportion of office visits and buprenorphine prescription fills that were provided out-of-network; however, we did not have extensive data on buprenorphine prescription fills.

TABLE 13. Median Out-of-Network Amount Paid for the Receipt of Common OUD Treatments for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007 and 2014
Service Category HMO,
2007, $
HMO,
2014, $
PPO,
2007, $
PPO,
2014, $
POS,
2007, $
POS,
2014, $
CDHP/
HDHP,
2007, $
CDHP/
HDHP,
2014, $
All Plans,
2007, $
All Plans,
2014, $
Inpatient, including detoxification, per day N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
Outpatient detoxification, per day NSD 1,100 NSD 927 NSD 873 NSD 1,275 NSD 964
Residential, per day 165 250 NSD 1,311 NSD 3,951 NSD 1,390 76 1,500
Intensive outpatient or partial hospitalization, per day 110 1,095 198 865 195 623 2678 839 198 850
Treat-and-release ED visits (all visits that never become inpatient stays) NSD 506 209 526 NSD 500 NSD 612 250 524
Outpatient office visit 108 126 78 114 71 119 145 109 80 113
Psychotherapy or behavioral therapy office visit 80 140 100 125 67 125 107 125 90 125
Buprenorphine or buprenorphine naloxone prescription fill 563 439 321 307 NSD NSD NSD NSD 563 539
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.

Additionally, for out-of-network services, there was a decrease in the amount paid for an ideal protocol of services, but this was driven almost exclusively by a decrease in the amount paid for buprenorphine out-of-network. This finding may be related to the fact that in 2014, 100 percent of insurance plans surveyed by Brandeis covered buprenorphine for the treatment of OUD, so they may have negotiated rates. It is also worth noting that additional drugs received Food and Drug Administration (FDA) approval during the study period. Another factor may be increasing use of generic formulations of buprenorphine in 2014.[28]

TABLE 14. Proportion of Service Received Out-of-Network Services for Common OUD Treatments for Enrollees in Larger Employer-Sponsored Private Health Insurance Plans Who Have OUD, 2007 and 2014
Service Category HMO,
2007, $
HMO,
2014, $
PPO,
2007, $
PPO,
2014, $
POS,
2007, $
POS,
2014, $
CDHP/
HDHP,
2007, $
CDHP/
HDHP,
2014, $
All Plans,
2007, $
All Plans,
2014, $
Inpatient, including detoxification, per day N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
Outpatient detoxification, per day NSD 22.4 NSD 22.9 NSD 36.4 NSD 30.1 NSD 25.9
Residential, per day 28.9 9.6 NSD 51.6 NSD 42.6 NSD 46.9 8.4 46.8
Intensive outpatient or partial hospitalization, per day 1.9 9.7 12.5 46.8 4.6 50.5 10.3 49.4 9.4 45.4
Treat-and-release ED visits (all visits that never become inpatient stays) 2.3 5.5 7.5 9.1 0.9 4.4 10.0 2.2 5.3 7.0
Outpatient office visit 7.8 5.2 21.7 15.7 21.0 14.6 6.8 21.4 18.9 15.8
Psychotherapy or behavioral therapy office visit 3.9 6.7 15.6 24.5 34.3 34.5 21.7 36.5 15.3 25.5
Buprenorphine or buprenorphine naloxone prescription fill 2.2 2.2 NSD 0.0 NSD NSD NSD NSD 0.4 0.2
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.

 

FIGURE 5. Cost of an Ideal 12-Month MAT Treatment Protocol by Health Plan Type if Services Were Delivered Entirely Out-of-Network
FIGURE 5, Bar Chart: The cost of an ideal 12-month MAT protocol by health plan type if services were delivered entirely out of network showed an annualized decrease of 1.8% from 2007 to 2014 in total, for HMO plans a decrease of 0.4% and for PPO plans a decrease of 1.7%.
SOURCE: Truven Health MarketScan CCAE Database, 2007 and 2014.
NOTE: Data were insufficient for PPOs, POS plans, CDHPs/HDHPs.

For the purposes of getting a sense of the proportional effect of lack of comprehensive insurance coverage on all individuals with OUD in private health insurance, we approximated the expenditure on a per enrollee basis, assuming that individuals are equally likely to be enrolled in any plan type. That is, in Table 15, we approximate the expense for not having coverage for a specific service on commercially insured individuals with OUD. We multiplied the out-of-network price paid for services by the proportion of plans in each category that did not provide coverage for that service. The only service for which we could calculate the amount paid at the plan type level was buprenorphine prescription fills; however, a limitation of our data was that we did not have any out-of-network claims for buprenorphine prescription fills among POS plans in our dataset. Nevertheless, we can see that increasing the rate of insurance coverage vastly reduced out-of-pocket expenses for individuals that would otherwise have had to pay the full out-of-network rate. This expense savings amounted to $2,027 per person on average across all insured individuals for buprenorphine alone.

TABLE 15. Estimated Effect, per Enrollee in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, of Lack of Coverage on Out-of-Pocket Expenditures for Common OUD Treatment Services, by Plan Type, 2007 and 2014
Service Category HMO,
2007, $
PPO,
2007, $
POS,
2007, $
CDHP,
2007, $
All Plans,
2007, $
HMO,
2014, $
PPO,
2014, $
POS,
2014, $
CDHP,
2014, $
All Plans,
2014, $
Inpatient, including detoxification, per day N/A N/A N/A N/A No data N/A N/A N/A N/A No data
Outpatient detoxification, per day N/A N/A N/A N/A NSD N/A N/A N/A N/A 3.86
Residential, per day N/A N/A N/A N/A 10.64 N/A N/A N/A N/A 240
Intensive outpatient or partial hospitalization, per day N/A N/A N/A N/A 3.96 N/A N/A N/A N/A 14.45
Treat-and-release ED visits (all visits that never become inpatient stays) N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
Outpatient office visit N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
Psychotherapy or behavioral therapy office visit N/A N/A N/A N/A 2.07 N/A N/A N/A N/A 0
Buprenorphine or buprenorphine naloxone prescription fill 208.29 18.32 NSD N/A 168.89 0 0 0 0 0
SOURCES: Truven Health MarketScan CCAE Database, 2007, 2014. Horgan CM, Stewart MT, Reif S, et al. Behavioral health services in the changing landscape of private health plans. Psychiatric Services. 2016; 67(6): 622-629.

Table 16 shows that between 2007 and 2014 there was growth in the out-of-network payments for the three most common services outside of the bundle of services included in MAT, except for intensive outpatient treatment in CDHPs/HDHPs. We do not have information on insurance coverage for these services from the Brandeis dataset. It should be noted that data were insufficient for some services, which could affect overall results, and data were unavailable for the rate of change for inpatient treatment across all service types. The greatest growth in the amount paid for intensive outpatient treatment was observed within HMOs, with a rate of 38.9 percent during that period; the least growth was observed for CDHPs/HDHPs, with a rate of -15.3 percent. The greatest growth in the amount paid for treat-and-release emergency department treatment was observed within PPOs, with a rate of 14.1 percent during that period. Data were insufficient for all other service types. We projected that for the time between 2014 and 2018 there would be a trend of growth for out-of-network payments across all service types.

TABLE 16. Median Out-of-Network Amount Paid for the Receipt of Common OUD Treatments Outside of the Ideal MAT Treatment Protocol for Enrollees in Large Employer-Sponsored Private Health Insurance Plans Who Have OUD, by Plan Type, 2007, 2014, and 2018 (projected)
Plan Type Service Category Mean
2007, %
Mean
2014, %
Median
2018, $
(projected)
Aggregate Change
2007-2014, %
Annualized Change
2007-2018, %
(projected)
HMO Inpatient, including detoxification, per day N/A N/A N/A N/A N/A
HMO Intensive outpatient or partial hospitalization, per day 110 1,095.0 1,287.3 38.9 25.1
HMO Treat-and-release ED visits (all visits that never become inpatient stays) NSD 506 594.9 NSD NSD
PPO Inpatient, including detoxification, per day N/A N/A N/A N/A N/A
PPO Intensive outpatient or partial hospitalization, per day 198.0 865.0 1016.9 23.4 16.0
PPO Treat-and-release ED visits (all visits that never become inpatient stays) 209.4 526.1 618.5 14.1 10.3
POS Inpatient, including detoxification, per day N/A N/A N/A N/A N/A
POS Intensive outpatient or partial hospitalization, per day 195.0 623.4 732.8 18.1 12.8
POS Treat-and-release ED visits (all visits that never become inpatient stays) NSD 500.4 588.3 NSD NSD
CDHP/HDHP Inpatient, including detoxification, per day N/A N/A N/A N/A N/A
CDHP/HDHP Intensive outpatient or partial hospitalization, per day 2,677.5 839.4 986.9 -15.3 -8.7
CDHP/HDHP Treat-and-release ED visits (all visits that never become inpatient stays) NSD 611.5 718.9 NSD NSD
SOURCE: Truven Health MarketScan CCAE Database, 2007, 2014.

 

DISCUSSION

This study investigated changes in the amounts paid of MAT for OUD for individuals with employer-sponsored health insurance. We included individuals covered by HMOs, POS plans, PPOs, and combined CDHPs and HDHPs. We reported the results by plan type and for the total sample. The analyses focused on an ideal 12-month MAT treatment protocol, but we also included payments across all plan types for five additional services, and payments at the plan type level for three additional services that individuals with OUD often need. Data were from 2007 and 2014, which were before and after phased implementation of major federal legislation enacted to increase insurance coverage and expand access to coverage of behavioral health care. This time period also encompassed the emergence of new FDA-approved opioid treatment medications. We projected results for certain variables into 2018 to better estimate near-future costs of care for individuals with OUD.

Cost Trends in OUD Treatment Related to MAT

Although the total amount paid for a 12-month MAT treatment protocol across all plan types did not increase relative to inflation, high growth in the health insurance premiums, deductibles, and co-insurance resulted in greater treatment expenses to beneficiaries. However, it is very important to note that our results showed that prior to 2007 (2003 was the only pre-2010 year data were available), 37 percent of HMOs and nearly 45 percent of POS plans did not offer coverage for buprenorphine-based treatments for OUD.[29] Our analysis indicates that lack of coverage would have resulted in out-of-pocket expenses of over $1,000 per insured person on average. That cost would be exclusively on those without coverage for this treatment and therefore would have been a much greater burden on some individuals than others. Between 2007 and 2014, the combined annual amount paid for the employee portion of health insurance and deductibles increased on average in excess of 10 percent per year for HMOs, which experienced the most rapid growth, and in excess of 4 percent per year for HDHPs, which had the highest combined deductibles and premiums paid by employees in both time periods. We did not find comparable increases in co-payments during the years studied. In particular, we found that among all plans considered, the proportion of office visits and buprenorphine prescription fills where a co-payment was charged decreased between 2007 and 2014. This may have been related to increased deductibles, which would have made it more difficult for patients to achieve spending at a level where co-payments could be charged. Finally, we found that the co-payments for the ideal 12-month MAT treatment protocol decreased during the study period.

Cost Trends in Other OUD Services

In addition to considering the services that were part of an ideal protocol of care for individuals receiving MAT for OUD, we also looked by plan type at the three most common other treatment types that were commonly used by the individuals with OUD in our sample. These service categories were inpatient treatment, including detoxification; intensive outpatient or partial hospitalization; and treat-and-release emergency department visits, or all emergency department visits that never become inpatient stays. Moreover, across all plan types we considered residential treatment, per day, and outpatient detoxification, per day.

Examination of the treatments outside the MAT treatment protocol over the course of our first study period (2007-2014) revealed that all treatment types had a general growth in amounts paid over time. This trend is projected to continue through 2018. Between 2007 and 2014, for the four types of health plans considered, the total payments for the three non-MAT treatment protocol treatment types that we considered at the plan type level increased annually by an excess of 3 percent per year, except for the cost of inpatient care in an HMO, which only grew by 0.9 percent per year during that period. Payments are projected to continue to increase through 2018. Moreover, for the two less common services, outpatient detoxification, per day, the rate of growth was lower than the rate of inflation between 2007 and 2004, 1.4 percent, and the rate of growth in daily payments for residential care was much faster at 16.3 percent.

The amount of growth for co-payments, co-insurance, and out-of-network payments was more varied over these same time periods. The mean co-payment paid for these three services across all types of insurance in the sample decreased for intensive outpatient treatment and inpatient care, including detoxification services. The lower co-payment across all plan types may be partially explained by a shift to plans with higher deductibles, which would result in more services being delivered below the deductible and thus not subject to co-payments. When we restricted the analysis to co-payments on services for which any co-payment was charged, we found that the median co-payment for these services remained constant between 2007 and 2014. For the services which we considered each specific plan type, only inpatient treatment services for PPOs and POS plans had a decline in the mean amount paid. Between 2014 and 2018, the amount paid for co-payments is projected to increase across all service types and insurance plans. The mean co-insurance rates also generally increased annually across all plan types, except for CDHP and HDHP coverage of inpatient treatment and PPO coverage of intensive outpatient treatment, which decreased. This result may be partially explained by higher deductibles, which resulted in fewer services involving co-insurance and would have the effect of reducing the mean co-insurance paid per service. Out-of-network payments also increased between 2007 and 2014 for all types of care except intensive outpatient treatment covered by CDHPs and HDHPs. We project that the expenses will continue to rise between 2014 and 2018.

It is possible that trends in increasing total expenses for these services across all plan types considered are a function of increasing demand for OUD treatment. As described in the Methods section, we consider it likely that the amounts paid for these treatments will follow more general trends in the cost of comparable health care services between 2014 and 2018 as the impact of policy changes stabilizes.

Limitations

Our study has several potential limitations. First, the composition of the sample differs between 2007 and 2014. Access to insurance, as well as the coverage available, expanded as a result of the policies that were implemented during our study period. Therefore, we do not know for certain if the costs of care for the individuals that were in our sample in 2007 would have been higher in 2014 by the exact amount we estimate. Moreover, the MarketScan CCAE Database sample is a convenience sample and this may be a limitation of our analysis as it is not representative of all commercially insured individuals in the United States. That said, it is a very large convenience sample, with 9,400,751 individuals in 2007 and 14,063,641 in 2014 that met the criteria of being in an employer-sponsored plan, with prescription drug data, enrolled at least 10 months of the year, aged 12-64 and enrolled in one of the four categories of plans considered. Thus, some of the risks of bias are reduced. An additional potential limitation is that we constructed an ideal 12-month treatment protocol for MAT that assumes that all individuals would need a specific bundle of services. However, we know that certain individuals may require services outside of that protocol. To overcome this limitation, we incorporate estimates of the costs of care for services outside of that protocol, which allows for supplemental calculation of the amounts paid including those services in the protocol. A final limitation is that we use data on employer-sponsored insurance from three sources to construct our estimates, each with different samples. Therefore, the results from each may not be generalizable to the others. Nevertheless, we assumed that they would be representative of the health insurance marketplace for our calculations, but this is a limitation of our approach. The direction of potential bias caused by this is unknown.

Future Directions

Our study indicates the need to assess whether an individual's willingness to pay for OUD treatment has changed in recent years. Although prior research indicates that behavioral health treatment use is highly "price inelastic,"[30], [31] we found increased utilization of behavioral health services even after the expenses increased. This finding may indicate that the composition of the sample of individuals with OUD has changed over time, and we may need to re-evaluate our understanding of the way in which these individuals decide whether to use services. Perhaps the perceived marginal value of treatment is higher now. With that said, our main task results revealed that the growth in the population with OUD exceeded the rate of growth in the utilization of these services, which may indicate that the expenses are deterring use. Further research is needed to understand whether this is the case.

It is also important to consider the role that Medicaid plays in service use over time. Additional research is needed to identify whether trends in Medicaid prices paid influence the price paid by private insurers or the out-of-pocket costs of the privately insured.

 

APPENDIX A. ICD-9 AND ICD-10 DIAGNOSTIC CODES FOR OUD

ICD-9-CM ICD-9 Description
30400 Opioid dependence-unspecified
30401 Opioid dependence-continuous
30402 Opioid dependence-episode
30403 Opioid type dependence in remission
30470 Opioid/other dep-unspecified
30471 Opioid/other dep-continuous
30472 Opioid/other dep-episode
30473 Opioid w/other drug dependence in remission
30550 Opioid abuse-unspecified
30551 Opioid abuse-continuous
30552 Opioid abuse-episodic
30553 Opioid abuse in remission
96500 Poisoning by opium (alkaloids), unspecified
96501 Poisoning by heroin
96502 Poisoning by methadone
96509 Poisoning by other opiates
E8500 Accidental poisoning by heroin
E8501 Accidental poisoning by methadone
E8502 Accidental poisoning by other opiates and related narcotics
E9800 Undetermined cause poisoning by opiates

 

ICD-10 ICD-10 Description
F111 Opioid abuse
F1110 Opioid abuse uncomplicated
F1112 Opioid abuse with intoxication
F11120 Opioid abuse with intoxication uncomplicated
F11121 Opioid abuse with intoxication delirium
F11122 Opioid abuse w/intoxication w/perceptual disturb
F11129 Opioid abuse with intoxication unspecified
F1114 Opioid abuse with opioid-induced mood disorder
F1115 Opioid abuse with opioid-induced psychotic disorder
F11150 Opioid abuse w/induced psychosis d/o w/delusions
F11151 Opioid abuse w/induced psychosis d/o w/hallucinations
F11159 Opioid abuse w/opioid-induced psychosis d/o unspecified
F1118 Opioid abuse with other opioid-induced disorder
F11181 Opioid abuse w/opioid-induced sexual dysfunction
F11182 Opioid abuse with opioid-induced sleep disorder
F11188 Opioid abuse with other opioid-induced disorder
F1119 Opioid abuse w/unspecified opioid-induced disorder
F112 Opioid dependence
F1120 Opioid dependence, uncomplicated
F1121 Opioid dependence, in remission
F11220 Opioid dependence with intoxication, uncomplicated
F11221 Opioid dependence with intoxication delirium
F1122 Opioid dependence with intoxication
F11222 Opioid dependence with intoxication with perceptual disturbance
F11229 Opioid dependence with intoxication, unspecified
F1123 Opioid dependence with withdrawal
F1124 Opioid dependence with opioid-induced mood disorder
F1125 Opioid dependence with opioid-induced psychotic disorder
F11250 Opioid dependence with opioid-induced psychotic disorder with delusions
F11251 Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F1128 Opioid dependence with other opioid-induced disorder
F11281 Opioid dependence with opioid-induced sexual dysfunction
F11282 Opioid dependence with opioid-induced sleep disorder
F11288 Opioid dependence with other opioid-induced disorder
F1129 Opioid dependence with unspecified opioid-induced disorder
F1190 Opioid use, unspecified, uncomplicated
F11920 Opioid use, unspecified with intoxication, uncomplicated
F11921 Opioid use, unspecified with intoxication delirium
F11922 Opioid use, unspecified with intoxication with perceptual disturbance
F11929 Opioid use, unspecified with intoxication, unspecified
F1193 Opioid use, unspecified with withdrawal
F1194 Opioid use, unspecified with opioid-induced mood disorder
F11950 Opioid use, unspecified with opioid-induced psychotic disorder with delusions
F11951 Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations
F11959 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified
F11981 Opioid use, unspecified with opioid-induced sexual dysfunction
F11982 Opioid use, unspecified with opioid-induced sleep disorder
F11988 Opioid use, unspecified with other opioid-induced disorder
F1199 Opioid use, unspecified with unspecified opioid-induced disorder
T400X1A Poisoning by opium, accidental (unintentional), initial encounter
T400X2A Poisoning by opium, intentional self-harm, initial encounter
T400X4A Poisoning by opium, undetermined, initial encounter
T401X1A Poisoning by heroin, accidental (unintentional), initial encounter
T401X2A Poisoning by heroin, intentional self-harm, initial encounter
T401X4A Poisoning by heroin, undetermined, initial encounter
T402X1A Poisoning by other opioids, accidental (unintentional), initial encounter
T402X2A Poisoning by other opioids, intentional self-harm, initial encounter
T402X4A Poisoning by other opioids, undetermined, initial encounter
T403X1A Poisoning by methadone, accidental (unintentional), initial encounter
T403X2A Poisoning by methadone, intentional self-harm, initial encounter
T403X4A Poisoning by methadone, undetermined, initial encounter

 

APPENDIX B. NDC CODES IDENTIFYING MAT

NDC Product Name Route of Admin Master Form Code Strength in MG Generic Name
00054-0188-13 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00054-0189-13 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
00093-5720-56 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00093-5721-56 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
00228-3154-03 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00228-3154-73 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00228-3155-03 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
00228-3155-73 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
00406-1923-03 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00406-1924-03 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
00490-0051-00 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00490-0051-30 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00490-0051-60 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
00490-0051-90 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
12496-1202-01 SUBOXONE SL FIL 2-0.5 Buprenorphine/Naloxone
12496-1202-03 SUBOXONE SL FIL 2-0.5 Buprenorphine/Naloxone
12496-1204-01 SUBOXONE SL FIL 4-1 Buprenorphine/Naloxone
12496-1204-03 SUBOXONE SL FIL 4-1 Buprenorphine/Naloxone
12496-1208-01 SUBOXONE SL FIL 8-2 Buprenorphine/Naloxone
12496-1208-03 SUBOXONE SL FIL 8-2 Buprenorphine/Naloxone
12496-1212-01 SUBOXONE SL FIL 12-3 Buprenorphine/Naloxone
12496-1212-03 SUBOXONE SL FIL 12-3 Buprenorphine/Naloxone
12496-1278-02 SUBUTEX SL TAB 2 Buprenorphine
12496-1283-02 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
12496-1306-02 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
12496-1310-02 SUBUTEX SL TAB 8 Buprenorphine
16590-0666-05 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
16590-0666-30 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
16590-0667-05 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
16590-0667-30 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
16590-0667-90 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
23490-9270-03 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
23490-9270-06 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
23490-9270-09 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
35356-0004-07 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
35356-0004-30 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
42291-0174-30 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
42291-0175-30 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
43063-0184-07 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
43063-0184-30 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
49999-0395-07 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
49999-0395-15 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
49999-0395-30 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
49999-0638-30 SUBUTEX SL TAB 2 Buprenorphine
49999-0639-30 SUBUTEX SL TAB 8 Buprenorphine
50383-0287-93 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
50383-0294-93 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
52959-0304-30 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
52959-0749-30 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
53217-0138-30 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
54123-0114-30 ZUBSOLV SL TAB 11.4-2.9 Buprenorphine/Naloxone
54123-0914-30 ZUBSOLV SL TAB 1.4-0.36 Buprenorphine/Naloxone
54123-0929-30 ZUBSOLV SL TAB 2.9-0.71 Buprenorphine/Naloxone
54123-0957-30 ZUBSOLV SL TAB 5.7-1.4 Buprenorphine/Naloxone
54123-0986-30 ZUBSOLV SL TAB 8.6-2.1 Buprenorphine/Naloxone
54569-5496-00 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
54569-5739-00 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54569-5739-01 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54569-5739-02 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54569-6399-00 SUBOXONE SL FIL 8-2 Buprenorphine/Naloxone
54569-6408-00 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
54868-5707-00 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54868-5707-01 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54868-5707-02 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54868-5707-03 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54868-5707-04 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
54868-5750-00 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
55045-3784-03 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
55700-0147-30 SUBOXONE SL FIL 8-2 Buprenorphine/Naloxone
55700-0184-30 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
55887-0312-04 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
55887-0312-15 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
59385-0012-01 BUNAVAIL MM FIL 2.1-0.3 Buprenorphine/Naloxone
59385-0012-30 BUNAVAIL MM FIL 2.1-0.3 Buprenorphine/Naloxone
59385-0014-01 BUNAVAIL MM FIL 4.2-0.7 Buprenorphine/Naloxone
59385-0014-30 BUNAVAIL MM FIL 4.2-0.7 Buprenorphine/Naloxone
59385-0016-01 BUNAVAIL MM FIL 6.3-1 Buprenorphine/Naloxone
59385-0016-30 BUNAVAIL MM FIL 6.3-1 Buprenorphine/Naloxone
63629-4028-01 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
63629-4034-01 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
63629-4034-02 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
63629-4034-03 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
63629-4092-01 SUBUTEX SL TAB 8 Buprenorphine
63874-1084-03 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
63874-1085-03 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
63874-1173-03 SUBUTEX SL TAB 8 Buprenorphine
63874-1174-03 SUBUTEX SL TAB 2 Buprenorphine
65162-0415-03 BUPRENORPHINE-NALOXONE SL TAB 8-2 Buprenorphine/Naloxone
65162-0416-03 BUPRENORPHINE-NALOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
66336-0015-30 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
66336-0016-30 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
68071-1380-03 SUBOXONE SL TAB 8-2 Buprenorphine/Naloxone
68071-1510-03 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
68258-2999-03 SUBOXONE SL TAB 2-0.5 Buprenorphine/Naloxone
63459-0300-42 VIVITROL IM GER 380 VIVITROL
65757-0300-01 VIVITROL IM GER 380 VIVITROL

 

APPENDIX C. CPT, REVENUE, AND HEALTHCARE COMMON PROCEDURE CODING SYSTEM SERVICE CODES

Category Code Description of CPT or Revenue Code Additional Codes
Residential H0010 Alcohol and/or drug services; subacute detoxification (residential addiction program inpatient) DX
Residential H0011 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) DX
Residential H0017 Behavioral health; residential (hospital residential treatment program), without room and board, per diem DX
Residential H0018 Behavioral health; short-term residential (non-hospital residential treatment program), without room and board, per diem DX
Residential H0019 Behavioral health; long-term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem DX
Residential T2048 Behavioral health; long-term care residential (non-acute care in a residential treatment program where stay is typically longer than 30 days), with room and board, per diem DX
Residential H0012 Alcohol and/or drug services; subacute detoxification (residential addiction program outpatient) DX
Residential H0013 Alcohol and/or drug services; acute detoxification (residential addiction program outpatient) DX
Residential 1001 (rev) Residential treatment--psychiatric DX
Residential 1002 (rev) Residential treatment--chemical dependency DX
Residential 90791 Psychiatric diagnostic evaluation, initial diagnostic interview, excludes medical services DX, POS
Residential 90792 Psychiatric diagnostic evaluation with medical services DX, POS
Residential 90801 Diagnostic interview examination *code deleted in 2013 and replaced by 90791* DX, POS
Residential 90802 Interactive diagnostic interview examination *code deleted in 2013 replaced by 90792* DX, POS
Residential 90816 Individual psychotherapy, 20-30 min *code deleted in 2013* DX, POS
Residential 90817 Individual psychotherapy with E/M, 20-30 min *code deleted in 2013* DX, POS
Residential 90818 Individual psychotherapy, 45-50 min *code deleted in 2013* DX, POS
Residential 90819 Individual psychotherapy with E/M, 45-50 min *code deleted in 2013* DX, POS
Residential 90821 Individual psychotherapy, 75-80 min *code deleted in 2013* DX, POS
Residential 90822 Individual psychotherapy with E/M, 75-80 min *code deleted in 2013* DX, POS
Residential 90823 Interactive individual psychotherapy 20-30 min *code deleted in 2013* DX, POS
Residential 90824 Interactive individual psychotherapy with E/M 20-30 min *code deleted in 2013* DX, POS
Residential 90826 Interactive individual psychotherapy, 45-50 min *code deleted in 2013* DX, POS
Residential 90827 Interactive individual psychotherapy with E/M 45-50 min *code deleted in 2013* DX, POS
Residential 90828 Interactive individual psychotherapy, 75-80 min *code deleted in 2013* DX, POS
Residential 90829 Interactive individual psychotherapy with E/M 75-80 min *code deleted in 2013* DX, POS
Residential 90832 Psychotherapy, 30 min DX, POS
Residential 90833 E/M plus psychotherapy add-on, 30 min DX, POS
Residential 90834 Psychotherapy, 45 min DX, POS
Residential 90836 E/M plus psychotherapy add-on, 45 min DX, POS
Residential 90837 Psychotherapy, 60 min DX, POS
Residential 90839 Psychotherapy for crisis DX, POS
Residential 90840 Psychotherapy for crisis, add-on for each additional 30 min DX, POS
Residential 90845 Psychoanalysis DX, POS
Residential 90847 Family psychotherapy, conjoint psychotherapy with patient present DX, POS
Residential 90849 Multiple-family group psychotherapy DX, POS
Residential 90853 Group psychotherapy, more than of a multiple-family group DX, POS
Residential 90857 Interactive group psychotherapy *code deleted in 2013* DX, POS
Residential 90862 Pharmacologic management *code deleted in 2013* DX, POS
Residential 90867 Therapeutic repetitive TMS DX, POS
Residential 90868 Subsequent TMS Delivery and Management DX, POS
Residential 90869 Subsequent TMS Motor Threshold Re-Determination with Delivery and Management DX, POS
Residential 90870 Electroconvulsive Therapy DX, POS
Residential 90875 Individual Psychophysiological Therapy Incorporating Biofeedback Training by any Modality, 20-30 min DX, POS
Residential 90876 Individual Psychophysiological Therapy Incorporating Biofeedback Training by any Modality, 45-50 min DX, POS
Residential 99221 Initial hospital care, per day, for the evaluation and management of a patient, low severity DX, POS
Residential 99222 Initial hospital care, per day, for the evaluation and management of a patient, moderate severity DX, POS
Residential 99223 Initial hospital care, per day, for the evaluation and management of a patient, high severity DX, POS
Residential 99231 Inpatient services, subsequent hospital care, low complexity DX, POS
Residential 99232 Inpatient services, subsequent hospital care, moderate complexity DX, POS
Residential 99233 Inpatient services, subsequent hospital care, unstable or high complexity DX, POS
Residential 99238 Hospital discharge services, 30 min or less DX, POS
Residential 99239 Hospital discharge services, more than 30 min DX, POS
Residential 99251 Inpatient consultation, self-limited or minor, 20 min at bedside DX, POS
Residential 99252 Inpatient consultation, low severity, 40 min at bedside DX, POS
Residential 99253 Inpatient consultation, moderate severity, 55 min at bedside DX, POS
Residential 99254 Inpatient consultation, moderate to high severity, 80 min at bedside DX, POS
Residential 99255 Inpatient consultation, moderate to high severity, 110 min at bedside DX, POS
IOP or Partial Hosp. G0410 Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45-50 min DX
IOP or Partial Hosp. G0411 Interactive group psychotherapy, in a partial hospitalization setting, approximately 45-50 min DX
IOP or Partial Hosp. H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education DX
IOP or Partial Hosp. H0035 Mental health partial hospitalization, treatment, less than 24 hours DX
IOP or Partial Hosp. H2001 Rehabilitation program, per 1/2 day DX
IOP or Partial Hosp. H2012 Behavioral health day treatment, per hour DX
IOP or Partial Hosp. S0201 Partial hospitalization services, less than 24 hours, per diem DX
IOP or Partial Hosp. S9480 Intensive outpatient psychiatric services, per diem DX
IOP or Partial Hosp. S9484 Crisis intervention mental health services, per hour DX
IOP or Partial Hosp. S9485 Crisis intervention mental health services, per diem DX
IOP or Partial Hosp. 0905 (rev) Intensive outpatient services--psychiatric DX
IOP or Partial Hosp. 0906 (rev) Chemical dependency DX
IOP or Partial Hosp. 0907 (rev) Community behavioral health program--day treatment DX
IOP or Partial Hosp. 0912 (rev) Partial hospitalization-less intensive DX
IOP or Partial Hosp. 0913 (rev) Partial hospitalization-intensive DX
IOP or Partial Hosp. h0009 Alc/drug services--acute detox (hosp inpt) DX, POS
IOP or Partial Hosp. g0378 Hospital observation service, per hour DX, POS
IOP or Partial Hosp. 90791 Psychiatric diagnostic evaluation, initial diagnostic interview, excludes medical services DX, POS
IOP or Partial Hosp. 90792 Psychiatric diagnostic evaluation with medical services DX, POS
IOP or Partial Hosp. 90801 Diagnostic interview examination *code deleted in 2013 and replaced by 90791* DX, POS
IOP or Partial Hosp. 90802 Interactive diagnostic interview examination *code deleted in 2013 replaced by 90792* DX, POS
IOP or Partial Hosp. 90816 Individual psychotherapy, 20-30 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90817 Individual psychotherapy with E/M, 20-30 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90818 Individual psychotherapy, 45-50 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90819 Individual psychotherapy with E/M, 45-50 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90821 Individual psychotherapy, 75-80 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90822 Individual psychotherapy with E/M, 75-80 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90823 Interactive individual psychotherapy 20-30 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90824 Interactive individual psychotherapy with E/M 20-30 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90826 Interactive individual psychotherapy, 45-50 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90827 Interactive individual psychotherapy with E/M 45-50 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90828 Interactive individual psychotherapy, 75-80 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90829 Interactive individual psychotherapy with E/M 75-80 min *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90832 Psychotherapy, 30 min DX, POS
IOP or Partial Hosp. 90833 E/M plus psychotherapy add-on, 30 min DX, POS
IOP or Partial Hosp. 90834 Psychotherapy, 45 min DX, POS
IOP or Partial Hosp. 90836 E/M plus psychotherapy add-on, 45 min DX, POS
IOP or Partial Hosp. 90837 Psychotherapy, 60 min DX, POS
IOP or Partial Hosp. 90839 Psychotherapy for crisis DX, POS
IOP or Partial Hosp. 90840 Psychotherapy for crisis, add-on for each additional 30 min DX, POS
IOP or Partial Hosp. 90845 Psychoanalysis DX, POS
IOP or Partial Hosp. 90847 Family psychotherapy, conjoint psychotherapy with patient present DX, POS
IOP or Partial Hosp. 90849 Multiple-family group psychotherapy DX, POS
IOP or Partial Hosp. 90853 Group psychotherapy, more than of a multiple-family group DX, POS
IOP or Partial Hosp. 90855 psych eval hosp records dx purposes DX, POS
IOP or Partial Hosp. 90857 Interactive group psychotherapy *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90862 Pharmacologic management *code deleted in 2013* DX, POS
IOP or Partial Hosp. 90867 Therapeutic repetitive TMS DX, POS
IOP or Partial Hosp. 90868 Subsequent TMS Delivery and Management DX, POS
IOP or Partial Hosp. 90869 Subsequent TMS Motor Threshold Re-Determination with Delivery and Management DX, POS
IOP or Partial Hosp. 90870 Electroconvulsive Therapy DX, POS
IOP or Partial Hosp. 90875 Individual Psychophysiological Therapy Incorporating Biofeedback Training by any Modality, 20-30 min DX, POS
IOP or Partial Hosp. 90876 Individual Psychophysiological Therapy Incorporating Biofeedback Training by any Modality, 45-50 min DX, POS
IOP or Partial Hosp. 99221 Initial hospital care, per day, for the evaluation and management of a patient, low severity DX, POS
IOP or Partial Hosp. 99222 Initial hospital care, per day, for the evaluation and management of a patient, moderate severity DX, POS
IOP or Partial Hosp. 99223 Initial hospital care, per day, for the evaluation and management of a patient, high severity DX, POS
IOP or Partial Hosp. 99224 Subsequent observation care/day 15 min DX, POS
IOP or Partial Hosp. 99225 Subsequent observation care/day 25 min DX, POS
IOP or Partial Hosp. 99226 Subsequent observation care/day 35 min DX, POS
IOP or Partial Hosp. 99231 Inpatient services, subsequent hospital care, low complexity DX, POS
IOP or Partial Hosp. 99232 Inpatient services, subsequent hospital care, moderate complexity DX, POS
IOP or Partial Hosp. 99233 Inpatient services, subsequent hospital care, unstable or high complexity DX, POS
IOP or Partial Hosp. 99234 Observation/inpatient hospital care 40 min DX, POS
IOP or Partial Hosp. 99235 Observation/inpatient hospital care 50 min DX, POS
IOP or Partial Hosp. 99238 Hospital discharge services, 30 min or less DX, POS
IOP or Partial Hosp. 99239 Hospital discharge services, more than 30 min DX, POS
IOP or Partial Hosp. 99251 Inpatient consultation, self-limited or minor, 20 min at bedside DX, POS
IOP or Partial Hosp. 99252 Inpatient consultation, low severity, 40 min at bedside DX, POS
IOP or Partial Hosp. 99253 Inpatient consultation, moderate severity, 55 min at bedside DX, POS
IOP or Partial Hosp. 99254 Inpatient consultation, moderate to high severity, 80 min at bedside DX, POS
IOP or Partial Hosp. 99255 Inpatient consultation, moderate to high severity, 110 min at bedside DX, POS
ED Visits 0450 (rev) ER-General DX
ED Visits 0451 (rev) EMTALA emergency medical screening services DX
ED Visits 0452 (rev) ER beyond EMTALA screening DX
ED Visits 0456 (rev) Urgent Care DX
ED Visits 0459 (rev) Other DX
ED Visits 0981 (rev) Professional fees-ER DX
ED Visits 99281 ED Services, self-limited or minor DX
ED Visits 99282 ED Services, low or moderate severity DX
ED Visits 99283 ED Services, moderate severity DX
ED Visits 99284 ED Services, high severity DX
ED Visits 99285 ED Services, high severity and pose immediate and significant threat to life or physiological function DX
Outpatient Visit 98960 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient; individual patient DX
Outpatient Visit 98961 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient; 2-4 patients DX
Outpatient Visit 98962 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient; 5-8 patients DX
Outpatient Visit 99078 Physician educational services rendered to patients in a group setting DX
Outpatient Visit 99201 Office or Other outpatient services, new patient, self-limited or minor, 10 min DX
Outpatient Visit 99202 Office or Other outpatient services, new patient, low to moderate severity, 20 min DX
Outpatient Visit 99203 Office or Other outpatient services, new patient, moderate severity, 30 min DX
Outpatient Visit 99204 Office or Other outpatient services, moderate to high severity, 45 min DX
Outpatient Visit 99205 Office or Other outpatient services, moderate to high severity, 60 min DX
Outpatient Visit 99211 This code is used for a service that may not require the presence of a physician. Presenting problems are minimal, and 5 min is the typical time that would be spent performing or supervising these services. DX
Outpatient Visit 99212 Established patient, self-limited or minor, 10 mins DX
Outpatient Visit 99213 Established patient, low to moderate severity, 15 mins DX
Outpatient Visit 99214 Established patient, moderate to high severity, 25 min DX
Outpatient Visit 99215 Established patient, moderate to high severity, 40 mins DX
Outpatient Visit 99217 This code is used to report all services provided on discharge from "observation status" if the discharge occurs after the initial date of "observation status." DX
Outpatient Visit 99218 Initial observation care, low severity DX
Outpatient Visit 99219 Initial observation care, moderate severity DX
Outpatient Visit 99220 Initial observation care, high severity DX
Outpatient Visit 99241 Office or other outpatient consultations, self-limited or minor, 15 min DX
Outpatient Visit 99242 Office or other outpatient consultation, low severity, 30 min DX
Outpatient Visit 99243 Office or other outpatient consultation, moderate severity, 40 min DX
Outpatient Visit 99244 Office or other outpatient consultation, moderate to high severity, 60 min DX
Outpatient Visit 99245 Office or other outpatient consultation, moderate to high severity, 80 min DX
Outpatient Visit 99341 Home services, new patient, low severity, 20 min DX
Outpatient Visit 99342 Home services, new patient, moderate severity 30 min DX
Outpatient Visit 99343 Home services, new patient, moderate to high severity, 45 min DX
Outpatient Visit 99344 Home services, new patient, high severity, 60 min DX
Outpatient Visit 99345 Home services, new patient, patient unstable or developed significant new problem, 75 min DX
Outpatient Visit 99347 Home services, established patient, low severity, 20 min DX
Outpatient Visit 99348 Home services, established patient, low to moderate severity 25 min DX
Outpatient Visit 99349 Home services, established patient, moderate to high severity, 40 min DX
Outpatient Visit 99350 Home services, established patient, moderate to high severity, patient may be unstable, 60 min DX
Outpatient Visit 99384 Initial evaluation of new patient, 12-17 years DX
Outpatient Visit 99385 Initial evaluation of new patient, 18-39 years DX
Outpatient Visit 99386 Initial evaluation of new patient, 40-64 years DX
Outpatient Visit 99387 Initial evaluation of new patient, 65 and over DX
Outpatient Visit 99394 Initial evaluation of established patient, 12-17 years DX
Outpatient Visit 99395 Initial evaluation of established patient, 18-39 years DX
Outpatient Visit 99396 Initial evaluation of established patient, 40-64 years DX
Outpatient Visit 99397 Initial evaluation of established patient, 65 and over DX
Outpatient Visit 99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 min DX
Outpatient Visit 99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 min DX
Outpatient Visit 99403 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 min DX
Outpatient Visit 99404 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 min DX
Outpatient Visit 99408 Counseling risk factor reduction and behavior change, 15-30 min, includes the administration of an alcohol and/or substance abuse screening tool and brief intervention DX
Outpatient Visit 99409 Counseling risk factor reduction and behavior change, 30 min or more DX
Outpatient Visit 99411 Group counseling services, preventative medicine, 30 min DX
Outpatient Visit 99412 Group counseling services, preventative medicine, 60 min DX
Outpatient Visit 99510 Home visit for individual, family, or marriage counseling DX
Outpatient Visit 99605 Medication therapy initial, 15 min new patient DX
Outpatient Visit 99606 Medication therapy initial, 15 min established pt DX
Outpatient Visit G0155 Services of clinical social worker in home health or hospice settings, each 15 min DX
Outpatient Visit G0176 Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 min or more) DX
Outpatient Visit G0177 Training and educational services related to the care and treatment of patient's disabling mental health problems per session (45 min or more) DX
Outpatient Visit G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention 15-30 min DX
Outpatient Visit G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and intervention, greater than 30 min DX
Outpatient Visit G0409 Social work and psychological services, directly relating to and/or furthering the patient's rehabilitation goals, each 15 min, face-to-face; individual (services provided by a corf-qualified social worker or psychologist in a corf) DX
Outpatient Visit G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 min DX
Outpatient Visit G0463 Hospital outpatient clinic visit for assessment and management of a patient DX
Outpatient Visit H0001 Alcohol and/or drug assessment DX
Outpatient Visit H0002 Behavioral health screening to determine eligibility for admission to treatment program DX
Outpatient Visit H0004 Behavioral health counseling and therapy, per 15 min DX
Outpatient Visit H0005 Alcohol and/or drug services; group counseling by a clinician DX
Outpatient Visit H0007 Alcohol and/or drug services; crisis intervention (outpatient) DX
Outpatient Visit H0014 Alc/drug ambulatory detox DX
Outpatient Visit H0016 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) DX
Outpatient Visit H0022 Alcohol and/or drug intervention service (planned facilitation) DX
Outpatient Visit H0031 Mental health assessment, by non-physician DX
Outpatient Visit H0034 Medication training and support, per 15 min DX
Outpatient Visit H0036 Community psychiatric supportive treatment, face-to-face, per 15 min DX
Outpatient Visit H0037 Community psychiatric supportive treatment program, per diem DX
Outpatient Visit H0039 Assertive community treatment, face-to-face, per 15 min DX
Outpatient Visit H0040 Assertive community treatment program, per diem DX
Outpatient Visit H2000 Comprehensive multidisciplinary evaluation DX
Outpatient Visit H2010 Comprehensive medication services, per 15 min DX
Outpatient Visit H2011 Crisis intervention service, per 15 min DX
Outpatient Visit H2013 Psychiatric health facility service, per diem DX
Outpatient Visit H2014 Skills training and development, per 15 min DX
Outpatient Visit H2015 Comprehensive community support services, per 15 min DX
Outpatient Visit H2016 Comprehensive community support services, per diem DX
Outpatient Visit H2017 Psychosocial rehabilitation services, per 15 min DX
Outpatient Visit H2018 Psychosocial rehabilitation services, per diem DX
Outpatient Visit H2019 Therapeutic behavioral services, per 15 min DX
Outpatient Visit H2020 Therapeutic behavioral services, per diem DX
Outpatient Visit H2035 Alcohol and/or other drug treatment program, per hour DX
Outpatient Visit H2036 Alcohol and/or other drug treatment program, per diem DX
Outpatient Visit H0046 Mental health services not otherwise specified DX
Outpatient Visit H0047 Alc/drug abuse svc not otherwise specified DX
Outpatient Visit H0050 Alc/drug brief intervention, per 15 min DX
Outpatient Visit M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders DX
Outpatient Visit S9475 Ambulatory setting substance abuse tx/detox DX
Outpatient Visit T1006 Alcohol and/or substance abuse services, family/couple counseling DX
Outpatient Visit T1012 Alcohol and/or substance abuse services, skills development DX
Outpatient Visit T1015 Clinic visit/encounter, all-inclusive DX
Outpatient Visit 0510 (rev) General clinic visit DX
Outpatient Visit 0513 (rev) Psychiatric clinic DX
Outpatient Visit 0515 (rev) Pediatric clinic DX
Outpatient Visit 0516 (rev) Urgent care clinic DX
Outpatient Visit 0517 (rev) Family practice clinic DX
Outpatient Visit 0519 (rev) Other clinic DX
Outpatient Visit 0520 (rev) Freestanding clinic, general DX
Outpatient Visit 0521 (rev) Clinic visit by member to RHC/FQHC DX
Outpatient Visit 0522 (rev) Home visit by RHC/FQHC practitioner DX
Outpatient Visit 0523 (rev) Family practice clinic DX
Outpatient Visit 0526 (rev) Urgent care clinic DX
Outpatient Visit 0527 (rev) Visiting nurse services to member's home in a home health shortage area DX
Outpatient Visit 0528 (rev) Visit by RHC/FQHC practitioner to other non-RHC/FQHC site (e.g., scene of accident) DX
Outpatient Visit 0529 (rev) Other Freestanding clinic DX
Outpatient Visit 0900 (rev) BH Treatment/services, general DX
Outpatient Visit 0902 (rev) Milieu therapy DX
Outpatient Visit 0903 (rev) Play therapy DX
Outpatient Visit 0904 (rev) Activity therapy DX
Outpatient Visit 0911 (rev) Rehabilitation DX
Outpatient Visit 0914 (rev) Individual therapy DX
Outpatient Visit 0915 (rev) Group therapy DX
Outpatient Visit 0916 (rev) Family therapy DX
Outpatient Visit 0917 (rev) Biofeedback DX
Outpatient Visit 0919 (rev) BH treatments DX
Outpatient Visit 0944 (rev) Drug rehabilitation DX
Outpatient Visit 0945 (rev) Alcohol rehabilitation DX
Outpatient Visit 0982 (rev) Outpatient services, fees DX
Outpatient Visit 0983 (rev) Clinic, fees DX
Outpatient Visit 90791 Psychiatric diagnostic evaluation, initial diagnostic interview, excludes medical services DX, POS
Outpatient Visit 90792 Psychiatric diagnostic evaluation with medical services DX, POS
Outpatient Visit 90801 Diagnostic Interview Examination DX, POS
Outpatient Visit 90802 Interactive diagnostic interview examination DX, POS
Outpatient Visit 90862 Pharmacologic management *code deleted in 2013* DX, POS
Outpatient Visit 90867 Therapeutic repetitive TMS DX, POS
Outpatient Visit 90868 Subsequent TMS Delivery and Management DX, POS
Outpatient Visit 90869 Subsequent TMS Motor Threshold Re-Determination with Delivery and Management DX, POS
Outpatient Visit 90870 Electroconvulsive Therapy DX, POS
Outpatient Codes: Psychotherapy Codes 90785 Psychotherapy complex interactive, add-on for "difficult" patient DX, POS
Outpatient Codes: Psychotherapy Codes 90804 Individual psychotherapy, insight-oriented, behavior modifying and/or supportive, in an office or outpatient facility, 20-30 min DX, POS
Outpatient Codes: Psychotherapy Codes 90805 Individual psychotherapy, insight-oriented, behavior modifying and/or supportive, in an office or outpatient facility, with medical evaluation and management DX, POS
Outpatient Codes: Psychotherapy Codes 90806 Individual therapy, 45-50 min DX, POS
Outpatient Codes: Psychotherapy Codes 90807 Individual therapy with med management DX, POS
Outpatient Codes: Psychotherapy Codes 90808 Individual therapy, 75-80 min DX, POS
Outpatient Codes: Psychotherapy Codes 90809 Individual therapy with med management DX, POS
Outpatient Codes: Psychotherapy Codes 90810 Interactive therapy 20-30 min DX, POS
Outpatient Codes: Psychotherapy Codes 90811 Interactive therapy, med management DX, POS
Outpatient Codes: Psychotherapy Codes 90812 Interactive therapy, 45-50 min DX, POS
Outpatient Codes: Psychotherapy Codes 90813 Interactive therapy, med management DX, POS
Outpatient Codes: Psychotherapy Codes 90814 Interactive therapy, 75-80 min DX, POS
Outpatient Codes: Psychotherapy Codes 90815 Interactive therapy, med management DX, POS
Outpatient Codes: Psychotherapy Codes 90857 Interactive group psychotherapy *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90832 Psychotherapy, 30 min DX, POS
Outpatient Codes: Psychotherapy Codes 90833 E/M plus psychotherapy add-on, 30 min DX, POS
Outpatient Codes: Psychotherapy Codes 90834 Psychotherapy, 45 min DX, POS
Outpatient Codes: Psychotherapy Codes 90836 E/M plus psychotherapy add-on, 45 min DX, POS
Outpatient Codes: Psychotherapy Codes 90837 Psychotherapy, 60 min DX, POS
Outpatient Codes: Psychotherapy Codes 90838 Individual Psychotherapy, 60 min with patient and/or family member when performed with an evaluation and management service DX, POS
Outpatient Codes: Psychotherapy Codes 90853 Group psychotherapy, more than of a multiple-family group DX, POS
Outpatient Codes: Psychotherapy Codes 90839 Psychotherapy for crisis DX, POS
Outpatient Codes: Psychotherapy Codes 90840 Psychotherapy for crisis, add-on for each additional 30 min DX, POS
Outpatient Codes: Psychotherapy Codes 90844 Psychotherapy 45-50 min DX, POS
Outpatient Codes: Psychotherapy Codes 90845 Psychoanalysis DX, POS
Outpatient Codes: Psychotherapy Codes 90847 Family psychotherapy, conjoint psychotherapy with patient present DX, POS
Outpatient Codes: Psychotherapy Codes 90849 Multiple-family group psychotherapy DX, POS
Outpatient Codes: Psychotherapy Codes 90863 Pharm management w/ psych add-on for prescribing psychologist in certain states DX, POS
Outpatient Codes: Psychotherapy Codes 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality, 20-30 min DX, POS
Outpatient Codes: Psychotherapy Codes 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality, 45-50 min DX, POS
Outpatient Codes: Psychotherapy Codes 99355 Individual psychophysiological therapy incorporating biofeedback training by any modality, 45-50 min DX, POS
Outpatient Codes: Psychotherapy Codes 90823 Interactive individual psychotherapy 20-30 min *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90824 Interactive individual psychotherapy with E/M 20-30 min *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90825 Interactive individual psychotherapy, 45-50 min *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90826 Interactive individual psychotherapy with E/M 45-50 min *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90827 Interactive individual psychotherapy, 75-80 min *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90828 Interactive individual psychotherapy with E/M 75-80 min *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90829 Interactive individual psychotherapy with E/M 75-80 min *code deleted in 2013* DX, POS
Outpatient Codes: Psychotherapy Codes 90839 Psychotherapy for crisis DX, POS
Outpatient Codes: Psychotherapy Codes 90840 Psychotherapy for crisis, add-on for each additional 30 min DX, POS
Outpatient: Peer Support H0038 Self-help/peer services, per 15 min DX, POS
Outpatient: Bupr service admin. J0571 Buprenorphine/naloxone, oral, less than or equal to 3mg buprenorphine (Buprenorphine oral 1mg) none
Outpatient: Bupr service admin. J0572 Buprenorphine/naloxone, oral, less than or equal to 3mg buprenorphine (Bupren/nal up to 3mg bupreno) none
Outpatient: Bupr service admin. J0573 Buprenorphine/naloxone, oral, greater than 3mg, but less than or equal to 3.1-6mg (Bupren/nal 3.1-6mg bupren) none
Outpatient: Bupr service admin. J0574 Buprenorphine/naloxone, oral, greater than 6mg, but less than or equal to 10mg buprenorphine (Bupren/nal 6.1-10mg bupre) none
Outpatient: Bupr service admin. J0575 Buprenorphine/naloxone, oral, greater than 10mg buprenorphine (Bupren/nal over 10mg bupreno) none
Outpatient: Methadone H0020 Alcohol and/or drug services; methadone administration and/or service (provision by a licensed program) none
Outpatient: Methadone S0109 Methadone, oral, 5mg none
Outpatient: Methadone J1230 Methadone, injection, up to 10mg none
Outpatient: Naltrexone J2315 Vivitrol, injection, 1mg none
Outpatient: Naloxone J2310 Naloxone Hydrochloride, injection, per 1mg none
Outpatient: case management H0006 Alcohol/and or drug services case management DX, POS
Outpatient: case management T1007 Treatment plan dev and/or mod for alcohol/sa DX, POS
Outpatient: case management T1017 Targeted case management, each 15 min DX, POS
Outpatient: case management T2023 Targeted case management, per month DX, POS
Outpatient: case management T1016 Case management, each 15 min DX, POS
IOP or Partial Hosp. H0008 Alcohol and/or drug services; subacute detoxification (hospital inpatient) DX, POS
IOP or Partial Hosp. H0009 Alc/drug services--acute detox (hosp inpt) DX, POS
Residential H0010 Alcohol and/or drug services; subacute detoxification (residential addiction program inpatient) DX
Residential H0011 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) DX
Residential H0012 Alcohol and/or drug services; subacute detoxification (residential addiction program outpatient) DX
Residential H0013 Alcohol and/or drug services; acute detoxification (residential addiction program outpatient) DX
Outpatient Visit H0014 Alc/drug ambulatory detox DX
Outpatient Visit S9475 Ambulatory setting substance abuse tx/detox DX

 

NOTES

  1. American Society of Addiction Medicine. The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. June 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24.

  2. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 4 Treatment Protocols. Treatment Improvement Protocol (TIP) Series, No. 40. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. https://www.ncbi.nlm.nih.gov/books/NBK64246/.

  3. Mojtabai R, Chen LY, Kaufmann CN, Crum RM. Comparing barriers to mental health treatment and substance use disorder treatment among individuals with comorbid major depression and substance use disorders. Journal of Substance Abuse Treatment. 2014; 46(2): 268-273.

  4. HealthCare.gov. Cost sharing. https://www.healthcare.gov/glossary/cost-sharing/.

  5. Reif S, Creedon TB, Horgan CM, et al. Commercial health plan coverage of selected treatments for opioid use disorders from 2003 to 2014. Journal of Psychoactive Drugs. 2017; 49(2): 1-9.

  6. American Society of Addiction Medicine. The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. June 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24.

  7. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 4 Treatment Protocols. (Treatment Improvement Protocol (TIP) Series, No. 40.) Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. https://www.ncbi.nlm.nih.gov/books/NBK64246/.

  8. Reif S, Creedon TB, Horgan CM, et al. Commercial health plan coverage of selected treatments for opioid use disorders from 2003 to 2014. Journal of Psychoactive Drugs. 2017; 49(2): 1-9.

  9. American Society of Addiction Medicine. The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.June 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24.

  10. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 4 Treatment Protocols. Treatment Improvement Protocol (TIP) Series, No. 40. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. https://www.ncbi.nlm.nih.gov/books/NBK64246/.

  11. Windham A, Gibbons B, Martinez D, Hughey L, Roberts J. (2018). Use of Medication-Assisted Treatment for Opioid Use Disorders in Employer-Sponsored Health Insurance: Final Report.

  12. Heller School for Social Policy and Management. Brandeis Health Plan Surveys on Alcohol, Drug Abuse, and Mental Health Services. https://sihp.brandeis.edu/ibh/brandeis-health-plan-survey/index.html.

  13. Horgan CM, Garnick DW, Merrick EL, Hodgkin D. Changes in how health plans provide behavioral health services. Journal of Behavioral Health Services & Research. 2009; 36(1): 11-24.

  14. Reif S, Creedon TB, Horgan CM, et al. Commercial health plan coverage of selected treatments for opioid use disorders from 2003 to 2014. Journal of Psychoactive Drugs. 2017; 49(2): 1-9.

  15. Reif S, Creedon TB, Horgan CM, et al. Commercial health plan coverage of selected treatments for opioid use disorders from 2003 to 2014. Journal of Psychoactive Drugs. 2017; 49(2): 1-9.

  16. Henry J. Kaiser Family Foundation and Health Research & Educational Trust (2014). Employer Health Benefits 2014 Annual Survey: Survey Design and Methods. Henry J. Kaiser Family Foundation and Health Research & Educational Trust. https://kaiserfamilyfoundation.files.wordpress.com/2014/09/8625-methods.pdf.

  17. Internal Revenue Service. Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans IRS Cat. No. 24216S. February 10, 2017. https://www.irs.gov/pub/irs-pdf/p969.pdf.

  18. American Society of Addiction Medicine. The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.June 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24.

  19. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Protocols. (Treatment Improvement Protocol (TIP) Series, No. 40. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. https://www.ncbi.nlm.nih.gov/books/NBK64246/.

  20. Heinzerling KG, Ober AJ, Lamp K, et al. SUMMIT: Procedures for Medication-Assisted Treatment of Alcohol or Opioid Dependence in Primary Care. RAND Corporation; 2016. http://www.integration.samhsa.gov/clinical-practice/mat/RAND_MAT_guidebook_for_health_centers.pdf.

  21. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2003-2013. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-75, HHS Publication No. (SMA) 15-4934. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.

  22. Mayo Clinic. Cognitive Behavioral Therapy. https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610.

  23. Mayo Clinic. Cognitive Behavioral Therapy. https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610.

  24. Mark TL, Olesiuk W, Ali MM, et al. Differential reimbursement of psychiatric services by psychiatrists and other medical providers. Psychiatric Services. E-pub ahead of print. December 1, 2017. https://doi.org/10.1176/appi.ps.201700271.

  25. Reif S, Creedon TB, Horgan CM, et al. Commercial health plan coverage of selected treatments for opioid use disorders from 2003 to 2014. Journal of Psychoactive Drugs. 2017; 49(2): 1-9.

  26. BLS Inflation Data, CPI-All Urban Consumers (Current Series), Health insurance in U.S. city average, all urban consumers, not seasonally adjusted. Retrieved from: https://beta.bls.gov/dataViewer/view/timeseries/CUUR0000SEME.

  27. Mark TL, Olesiuk W, Ali MM, et al. Differential reimbursement of psychiatric services by psychiatrists and other medical providers. Psychiatric Services. E-pub ahead of print. December 1, 2017. https://doi.org/10.1176/appi.ps.201700271.

  28. Sontag D. Addiction treatment with a dark side. The New York Times. November 16, 2013.

  29. Reif S, Creedon TB, Horgan CM, et al. Commercial health plan coverage of selected treatments for opioid use disorders from 2003 to 2014. Journal of Psychoactive Drugs. 2017; 49(2): 1-9.

  30. Soumerai SB, McLaughlin TJ, Ross-Degnan D, Casteris CS, Bollini P. Effects of limiting Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. New England Journal of Medicine, 1994; 331(10): 650-655.

  31. Barry CL, Frank RG, McGuire TG. The costs of mental health parity: still an impediment? Health Affairs, 2006; 25(3): 623-634.


Use of Medication-Assisted Treatment for Opioid Use Disorders in Employer-Sponsored Health Insurance

This report was prepared under contract #HHSP233201600023I between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Truven Health Analytics. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact the ASPE Project Officers, Laurel Fuller and D.E.B. Potter, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201; Laurel.Fuller@hhs.gov.

Reports Available

Use of Medication-Assisted Treatment for Opioid Use Disorders in Employer-Sponsored Health Insurance: Final Report

Use of Medication-Assisted Treatment for Opioid Use Disorders in Employer-Sponsored Health Insurance: Out-of-Pocket Costs