BISMARCK - North Dakota Attorney General Wayne Stenehjem issued an opinion Friday concluding that some plans offered by two major health insurers likely fail to comply with federal law by excluding coverage for residential treatment of adults for substance abuse.
The opinion applied to so-called “metallic plans” under the Affordable Care Act sold on the new health insurance marketplace in North Dakota by the Sanford Plan and Blue Cross Blue Shield of North Dakota.
A determination of whether similar coverage is adequate under so-called “grandfathered plans” - with enrollment as of March 23, 2010 – ultimately will hinge on interpretations by federal and state officials, Stenehjem concluded.
Health insurers and others still were studying the ramifications of Stenehjem’s opinion, which came in response to questions posed by Sen. Tim Mathern, D-Fargo.
“My team and I are still in the process of reviewing the AG opinion,” said Adam Hamm, North Dakota insurance commissioner. “As such, we will not be in a position to comment on the opinion today.”
Similarly, a spokeswoman for the North Dakota Department of Human Services, which administers Medicaid, said officials are reviewing the opinion and could not comment Friday.
Blue Cross Blue Shield, North Dakota’s dominant private health insurer, issued a brief statement Friday.
The North Dakota Blues have been collaborating with state insurance officials and others “to gain a better understanding of the situation to ensure that” plans it offers “comply with both state and federal law,” spokeswoman Andrea Dineen said in a statement.
Ruth Krystopolski, president of the Sanford Health Plan, said she also is working to ensure that its plans comply with the law in their coverage of residential treatment for substance abuse in light of Stenehjem’s opinion.
“We are working diligently with the Department of Insurance to make sure all our plans are compliant,” she said.
“I assume that there will be coverage” for adults receiving residential treatment for substance abuse. “How it’s covered is what we’re trying to determine,” Krystopolski said.
Mathern said he was pleased with Stenehjem’s conclusion that North Dakota’s benchmark insurance plan, which must provide what are considered essential benefits under the Affordable Care Act, is inadequate in its coverage for adults requiring residential treatment for substance abuse.
“To me, it does clarify that there was an arbitrary reduction of benefits that was contrary to federal and state law so these benefits must be reinstated,” Mathern said.
Although Stenehjem’s conclusion about the plans’ compliance under state law was limited, his determination that they failed to comply with federal law likely decides the issue, he said.
“Federal law generally trumps state law,” Mathern said. “I think insurance companies will be forced to change their policies and more people will get treatment, which is positive.”
