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

​​​​​​​​Last Updated: November 19, 2020

Introduction

In response to Wisconsin’s opioid overdose epidemic, Governor Scott Walker created the Task Force on Opioid Abuse under Executive Order #214. According to data collected by the State of Wisconsin, Department of Health Services:

Drug overdose deaths in Wisconsin increased 376% during a 15-year period.

  • There were 246 deaths in 2000 compared to 1,171 deaths in 2017.
  • The age-adjusted rate during the same period went from 4.6 per 100,000 to 18.5 per 100,000.​

From 2000 to 2017, approximately 35% of the drug overdose deaths involved prescription opioids (not including fentanyl).

  • The total number of deaths due to non-fentanyl prescription opioids increased 315%, from 58 cases in 2000 to 241 in 2017.
  • While death from heroin overdose accounted for 34% of all drug overdose deaths, heroin overdose deaths increased 15 times, from 28 deaths in 2000 to 407 deaths in 2017.
  • Fentanyl overdose deaths are an emerging concern for Wisconsin. Fentanyl overdose deaths accounted for 39% of all drug overdose deaths, increasing 1,900%, from 23 deaths in 2000 to 460 deaths in 2017.

From 2005 to 2017, the total number of drug-related hospital emergency room visits and hospitalizations nearly tripled, increasing from 9,868 to 26,373.

  • 63% of the hospital discharges involved a stay of more than 24 hours (hospitalization).
  • 75% of the hospital discharges were due to substance use disorders (SUDs).



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) of 1974, 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.

Effective January 1, 2014, 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 (co-pays, co-insurance, 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

Questions or problems with the complaint form?



​Report of the Survey of Opioid Addiction Treatment Coverage

In February 2017, OCI conducted a survey of health insurers regarding their coverage for treatment of opioid addiction. The survey was sent to 35 insurance companies who represented approximately 85% of Wisconsin’s health insurance market for 2016. All 35 insurers responded to the survey.

The survey was in response to Governor Walker’s Executive Order #228 relating to the Implementation of the Recommendations of the Co-Chairs of the Governor’s Task Force on Opioid Abuse (Task Force). The Task Force recommended OCI conduct a survey of major insurers in Wisconsin regarding their coverage of opioid addiction treatment and report the results of the survey to the Task Force.

The survey requested information from 2014 through 2016 related to the insurers’ Wisconsin group and individual fully insured health insurance business. Insurers were asked not to include information about their Medicare plans or the self-insured business they administered. Questions were included about services covered by the plans, medications covered by their drug formularies, limitations and barriers to coverage, and coverage options after discharge from hospital or intensive outpatient treatment.



Other Resources
 
PREVENTION
Protect yourself & your family
TREATMENT
 
RECOVERY


​Find Out More

Department of Health Services
1 West Wilson Street Madison, Wisconsin 53702
(608) 266-1865
Office of the Commissioner of Insurance
P.O. Box 7873
Madison, Wisconsin 53707-7873
(608) 266-0103 (Madison)
(800) 236-8517 (Statewide)
oci.wi.gov

For questions regarding the federal Mental Health Parity and Addiction Equity Act, contact:
 
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services
Attn: CMS-4137-NC
P.O. Box 8017
Baltimore, MD 21244-8010
(800) 633-4227
(877) 486-2048 TTY
 
Employee Benefits Security Administration (EBSA)
U.S. Department of Labor (DOL)
200 Constitution Avenue, N.W.
Washington, DC 20210
(866) 4-USA-DOL
(866) 487-2365)