OCI > Fact Sheet on the Treatment of Opioid Addiction & Other Substance Use Disorders

Fact Sheet on the Treatment of Opioid Addiction & Other Substance Use Disorders

Last Updated: June 27, 2023

Printable version of publication: Fact Sheet on the Treatment of Opioid Addiction & Other Substance Use Disorders

The Task Force on Opioid Abuse was created in response to Wisconsin’s opioid overdose epidemic. According to data collected by the State of Wisconsin Department of Health Services :

There was a 16% increase in opioid overdose deaths in 2021 from 2020.
In 2021 Wisconsin saw 3,133 opioid-related emergency room visits: an increase of 4% from 2020.

Opioid-related deaths totaled 839 in 2018 and 1,427 in 2021; an increase of 70%.

Coverage by Law

Wisconsin law requires certain health insurance policies including inpatient, outpatient, and transitional treatment benefits to treat nervous and mental disorders and substance use disorders. [s. 632.89, Wis. Stat.] This law applies to group health insurance policies and contracts, self-insured state governmental health plans, and individual health policies issued in Wisconsin. For individual health insurance policies, the Wisconsin law applies only to the extent an insurer elects to offer coverage.

Federal employee group plans (e.g., postal carrier's plans) and self-insured employer group plans falling within the terms of the federal Employee Retirement Income Security Act (ERISA), are exempt from Wisconsin law. Wisconsin law does not apply to most policies issued to a group based in another state if both the policyholder and group exist primarily for purposes other than to procure insurance and fewer than 25% of the insured persons are Wisconsin residents.

The federal Affordable Care Act requires all non-grandfathered individual and small employer plans (1 to 50 employees) to cover the treatment of nervous and mental disorders or substance use disorders as an essential health benefit. This means coverage cannot be subject to any annual or lifetime dollar limits.

Additionally, MHPAEA (also known as the mental health parity law) requires coverage provided by a group health benefit plan, a governmental self-insured health plan, or an individual health plan for the treatment of mental health, behavioral health, and substance use disorders must be equal to the coverage offered for medical and surgical treatments.

Mandatory Coverage

Under state law, three services must be covered:

Inpatient Services

Services for the treatment of substance use disorders provided to an insured in a hospital

Outpatient Services

Nonresidential services for the treatment of substance use disorders provided to an insured by any of the following:

A program in an outpatient treatment facility approved by the Department of Health Services
A licensed physician who has completed a residency in psychiatry
A psychologist licensed under Wisconsin law
A licensed mental health professional who specializes in mental health or substance use disorders

Transitional Treatment Services

Services provided to an insured in a less restrictive manner than are inpatient hospital services but in a more intensive manner than are outpatient services. (Programs providing these services are certified by the Wisconsin Department of Health Services.)

Medical Necessity

All plans and policies affected by the law must provide both inpatient and outpatient services. However, a group health benefit plan, a governmental self-insured health plan, and an individual health benefit plan providing coverage for the treatment of mental health disorders or substance use disorders must provide the criteria for determining medical necessity under the plan with respect to that coverage.

Denials

If one of these plans denies coverage for the treatment of mental health disorders or substance use disorders, they must explain to the insured the reason for the denial. This requirement is in addition to complying with current law with respect to explaining restrictions or terminations of coverage.

Deductibles

An insurer may apply the same deductible amount and/or copayment amount to substance use disorders they apply to all other benefits. Coverage for treatment of mental health and substance use disorders may be no more restrictive in the following areas than the most common limitations applied to other coverage under the plan:

exclusions and limitations
deductibles
copays
coinsurance
annual and lifetime payment limitations
out-of-pocket limits
out-of-network charges
day, visit, or appointment limits
limitations regarding referrals to non-physician providers and treatment programs
duration or frequency of coverage limits under the plan

Prescription Drugs

Prescription drugs are also included as part of the coverage for the treatment of substance use disorders, but only if they are provided as part of your insurance plan. Prescription drugs are covered if the drugs are prescribed for a patient who is receiving treatment on either an inpatient or outpatient basis, and if the prescription drugs are for the treatment of substance use disorders. If a health plan does not provide coverage for prescription drugs, then they are not included as part of the mandated coverage.

Contact your health insurer prior to seeking treatment.

As always, confirm that the treatment you want to pursue is covered by your health insurance plan. Confirm the provider, both the entity and practitioner, is in your network. Also, discuss your out-of-pocket expenses for seeking treatment (copays, coinsurance, deductibles, etc.).

Disputes Related to Coverage

If you have a specific complaint about your health insurance, you should first contact your insurance company or agent for assistance. If you do not receive an answer, you may complete the Office of the Commissioner of Insurance (OCI) complaint form to receive an answer to your question or to file a complaint.

What types of complaints does OCI handle?

OCI handles complaints involving health, life and annuity, and property and casualty insurance companies and their agents. Examples of complaints include: coverage issues, claim disputes, premium problems, sales misrepresentations, policy cancellations, and refunds. Either the insured individual or his or her representative may file a complaint.

How to file a complaint

Complete it online: oci.wi.gov/Complaints
Mail it to:
Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873
Or Fax it to (608) 264-8115.

Questions or problems with the complaint form?