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Substance abuse bill keeps coverage for inpatient care

The Legislature on Thursday was poised to approve a bill intended to address the state’s opioid addiction crisis, including controversial provisions that curtail insurers’ ability to deny coverage for addiction treatment.

The bill requires coverage for at least 14 days of inpatient detoxificiation and post-detox care, bars insurers from determining whether any addiction treatment -- inpatient or outpatient -- is medically necessary, and removes the requirement to obtain “prior authorization” from an insurer before entering substance use treatment.

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These rules -- which would not take effect until late next year -- apply to both commercial insurance and managed care plans in the MassHealth program for low-income people.

“Addiction is a matter of life and death for many,” Senate President Therese Murray said at a State House press conference Thursday morning, at which she announced that lawmakers had reached agreement on a final bill that resolves differences between separate versions passed earlier by the House and Senate. “The cost of addiction to society is astronomical.”

The bill includes other provisions aimed at preventing addiction and tracking the problem, but the insurance restrictions stirred the most debate.

Health insurance companies said the new rules would increase costs and encourage unnecessary inpatient care. They argued that for many patients, outpatient treatment is as effective as inpatient, and that the 14-day minimum -- while less than the 21 days in the original Senate bill -- would fuel the perception that inpatient care is the best option.

But patient advocates and treatment centers said the bill would remove obstacles to treatment that had prevented many from getting the care they needed.

“If this was any other disease, we would’ve addressed this a long time ago,” said Representative Elizabeth A. Malia, a Jamaica Plain Democrat. “We don’t want to go to any more funerals of our constituents, our friends and, worst of all, our families.”

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Senator Jennifer L. Flanagan, a Leominster Democrat who was the bill’s chief sponsor, said the legislation did not promote one type of treatment. “It’s not our job to tell people how to enter into treatment,” she said. “But it’s our job to help them enter into the treatment they they feel is necessary for them and their families.”

The bill’s insurance provisions take effect in October 2015. Meanwhile, the state’s Center for Health Information and Analysis is conducting a cost-benefit analysis of its mandates.

Vic DiGravio, president and CEO of the Association for Behavioral Healthcare, a providers’ trade group, called the bill “a bold step forward” that could be “a historic change in how people access treatment.”

But Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans, said the legislation runs contrary to medical evidence. “Many national and local experts in substance abuse treatment have raised concerns and I’m alarmed that their concerns weren’t addressed in the final legislation,” she said. Pellegrino said that people who geninely need inpatient care may have trouble finding beds because they will be filled by people who could recover as outpatients.

Other provisions in the sweeping legislation seek to encourage use of painkillers that are less likely to be used inappropriately by addicts. Pharmacists will be required to dispense drugs formulated to prevent abuse, such as drugs that cannot be crushed for injection or snorting -- unless directed otherwise by a physician. Insurers will be barred from charging higher co-payments on these “abuse-deterrent” drugs.

The bill authorizes the commissioner of public health to declare a drug “Schedule 1” -- having no medical use and thus illegal -- “if it poses an imminent hazard to public safety and is not already listed in a different schedule.”

It also requires the Department of Public Health to report on whether physicians are consulting the state’s database of controlled-substances prescriptions, known as the Prescription Monitoring Program, to see if their patients are obtaining prescriptions from multiple doctors. Earlier versions of the bill would have required physicians to register to use the database.

The bill requires all insurance carriers to reimburse for substance abuse treatment services delivered by a licensed alcohol and drug counselor.

The bill also requires the medical examiner to report deaths attributed to a controlled substances and hospitals to report the number of infants born exposed to a controlled substance.

Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer
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