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Gap in addiction treatment from ‘essential benefits’ standard

FARGO — There’s an unintended gap in adult residential treatment for addictions because of North Dakota’s selection of the basic “essential services” coverage under the Affordable Care Act, service providers and mental health advocates say.

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As a result, some people with addictions who require residential treatment are unable to access services and are ending up in emergency rooms or will be shifted to already overcrowded regional state human service centers, they say.

“It’s truly a sad state of affairs,” said Kurt Snyder, executive director of Heartview Foundation in Bismarck, which treats alcohol and drug addictions.

Access to residential addiction services, especially in western North Dakota, already was poor. The base coverage plan for insurance sold through the new marketplace does not cover residential treatment for addictions, Snyder and others said.

The lack of access broadened, however, as insurers effectively made what was intended as a coverage “floor” into a ceiling, Snyder and others said.

Because addicts have lost control, some require residential stays to remove them from the environment and situations that fed their addictions.

Those who cannot be adequately treated with outpatient care will reach crisis, and go elsewhere for treatment, Snyder said.

“These people cycle in and out of high-cost care,” he added. “It’s a major problem. Residential is an essential piece. Without residential care we can’t effectively treat our citizens.”

Greg LaFrancois, chief executive officer of Prairie St. John’s in Fargo, said the reduced support for residential addiction services will compound problems the state’s mental health providers already struggle with because services have not kept up with demand.

“Over time, it’s going to limit or eliminate those services from being offered,” he said. “New providers will not enter this market. Access is difficult now.”

North Dakota’s mental health services have strained to keep up with population growth, a culture of binge drinking and the rising epidemic of prescription drug abuse, providers said.

Previously, under mandates for mental health coverage under state law dating back to the 1990s, North Dakota required residential addiction coverage.

Sen. Tim Mathern, D-Fargo, has asked Attorney General Wayne Stenehjem for an opinion to address what he believes is a contradiction in law.

Mathern believes the state mandate should override the limits imposed by the essential benefits plan, selected by the North Dakota Legislature with input from Insurance Commissioner Adam Hamm and approved by federal officials.

Stenehjem said he will issue an opinion, and acknowledged the problems some are having accessing residential addiction services, but otherwise declined to comment.

Hamm also declined to comment, citing an investigation by his office involving complaints against Blue Cross Blue Shield of North Dakota involving restricted access to residential treatment for addictions.

An administrator for Blue Cross Blue Shield acknowledged there have been complaints. The North Dakota Blues argued against selecting the benchmark essential benefits plan adopted by the state, modeled after a Sanford Plan option.

“As part of those changes, coverage for residential treatment has changed, and in some cases, been reduced from plans previously offered by BCBSND,” Sharon Fletcher, a Blues senior vice president, said in a statement.

Blue Cross Blue Shield has recognized the need to “provide boarding for some members while they receive substance abuse treatment,” through what Fletcher described as a flexible case management.

“We recognized a gap and made the decision to provide support by offering a flexible case management option to aid members in their recovery efforts,” she said in the statement.

Sen. Judy Lee, R-West Fargo, said part of the controversy stems from disagreements over the appropriate level and setting of treatment. Over time, she said, more services have been offered in the “least restrictive setting possible,” with the goal of delivering more care in homes and communities.

“Those changes might have been made anyway because of changes in treatment,” Lee said, referring to the restrictions imposed by the base coverage level established for marketplace plans.

“There’s an argument between the providers and insurers over what defines appropriate treatment,” she said. “The whole question is quite complicated.”

Not everyone who was getting residential treatment required it under new standards, Lee said.

Lee and Mathern are two of four lawmakers serving on a task force that is examining gaps in mental health services in North Dakota. The task force will report its advisory findings to an interim legislative committee exploring the issue, with legislative responses possible when lawmakers convene next year.

Lee said she did not vote in favor of the essential benefits plan the state adopted, but now that it is in place, the benchmark cannot be changed “willy nilly.”

Mathern, who is public policy director for Prairie St. John’s, regards the situation as more dire.

“My concern is we actually had a fairly robust system that’s coming apart, that has been unraveling over the past couple of years,” he said.

“People eventually need hospitalization if they don’t get better from outpatient or residential — less intensive, less acute — treatment,” he said. “Hospitalization is a higher cost of treatment. That’s the really sad thing about this.”

Susan Helgeland, the former director of Mental Health America in North Dakota and a leading advocate for behavioral health services, said the restriction on residential treatment for adults with addictions is an example of the lack of equal treatment for those with behavioral health problems.

“We’re going backwards here,” she said, noting that state mandates required such coverage. “Why can’t behavioral health get equal treatment? Clearly we need a reform of that because the brain is part of the body. Why can’t we do this?”

In her statement, Fletcher said Blue Cross Blue Shield, as it works to implement the Affordable Care Act provisions, will “continue to encourage the North Dakota Legislature to evaluate the benchmark plan that was selected.”

Patrick Springer

Patrick Springer first joined the reporting staff of The Forum in 1985. He can be reached by calling 701-241-5522. Have a comment to share about a story? Letters to the editor should include author’s name, address and phone number. Generally, letters should be no longer than 250 words. All letters are subject to editing. Send to