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ACA Requires Parity Between Mental, Physical Disorders -- Will Insurers Comply?

Cost isn’t the only problem. Some addicts may wind up without care because there simply aren’t enough treatment facilities in New Jersey. There was already a dearth of facilities to which addicts could go for treatment even before the ACA was passed. Now, with thousands and thousands of additional New Jersey residents having health insurance, addiction specialists say the need for additional resources may become dire.

“There’s a lot of unmet need already, in terms of alcohol and drug use treatment. And suddenly, four million people across the country who have drug and alcohol problems, from homeless people to working mothers, will suddenly have insurance coverage, and the number of people seeking treatment could double over time, depending on how many people come forth,” Wentz said.

According to the state Department of Human Services’ Division of Mental Health and Addiction Services, there are some 87,140 people in New Jersey currently seeking treatment. Of that figure, some 31,145 did not receive the treatment they sought, Wentz said. And some estimate as many as 104,000 more people will be newly eligible for services under the Medicaid expansion.

Changes made last year to the Diagnostic and Statistical Manual (DSM) of mental disorders, used by mental health professionals to diagnose the type and severity of an illness and the appropriate treatment, will not help matters, addiction specialists say. Under the DSM-IV, to be diagnosed with a “substance use disorder” -- a categorization that makes one more likely to be covered by insurance -- the diagnostic criteria required an individual to have only one symptom.

But in the revised version, called DSM-5, people must have at least two symptoms to be categorized with even a mild substance use disorder. Critics of the revisions say it will now be harder to meet these requirements.

“That is an avenue where I think some insurers may take to forestall some of this work that has gone into the parity and the Affordable Care Act,” Baxter said.

In the end, addiction specialists say it may take court intervention to get the insurance industry to comply with the parity law.

“What’s going to have to happen is that when the ACA is in full effect, and insurance companies balk at having to provide an equal level of benefits, litigation is unfortunately going to have to occur,” Baxter said. “Because when you have rules and regulations and some entities say, ‘Okay, I know what the rule is, and I know what the regulation is, but I’m not going to do it, you have to make them do it. And that normally occurs through some kind of litigation.”

Caren Chesler is a freelance writer, based in Ocean Grove, whose work has appeared in various general-interest and business publications, including The New York Times. She also served as Statehouse reporter for the Asbury Park Press.

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