Does the pain management treatment law apply to all health insurance plans?
The Division of Insurance (“DOI”) requires that Massachusetts-issued insured health plans provide pain management services. The pain management treatment law applies to all insured health benefit plans issued to individuals and employers in Massachusetts, including health plans insured through the Massachusetts Health Connector (e.g., all ConnectorCare Health Plans). The pain management law also applies to Massachusetts employee health plans offered by the Group Insurance Commission, but these are not subject to Division of Insurance jurisdiction.
How can someone know if their health plan is subject to the pain management treatment law?
Individuals should contact their employer’s human resources representative or their health insurance plan to understand whether they are in an insured health benefit plan issued in Massachusetts that is subject to the protections of the pain management treatment law. Many large employers self-fund employee health benefits, meaning that they pay the benefits from their own resources rather than buying an insured health plan from an Insurance Carrier. These self-funded health plans are exempt from state mandated benefit requirements, including the pain management treatment law.
What are pain management services?
Pain management refers to the assessment, diagnosis, and treatment of pain. The aim of pain management is to alleviate pain, improve function, and enhance the quality of life for individuals experiencing pain.
What treatment may be available to treat pain?
Insurance carriers cover opioid products to treat pain, but health concerns discourage overreliance on opioid products for pain management. Massachusetts insurance carriers also are required to develop a plan to provide adequate coverage and access to a broad spectrum of pain management services that are not based on prescribing of opioids.
What non-opioid services are available to treat pain?
The Massachusetts Division of Insurance (Division) expects carriers to make a broad spectrum of services available that includes, but is not limited to, non-medication, non-surgical treatment modalities and non-opioid medication treatment options that serve as alternatives to opioids.
Carriers are required to present their full list of pain management services for the Division of Insurance’s approval. In its review, the Division considers the adequacy of access to a broad spectrum of pain management services and any carrier policies that may create unduly preferential coverage to prescribing opioids without other pain management modalities. The Division maintains a list of Carriers' Alternatives to Treat Pain.
Carriers annually distribute educational materials to providers within their networks and to members about the pain management access plans developed, and they make information about the plans publicly available on their websites. You should consider contacting your health plan for more information about options that may be available.
Are non-opioid pain management services subject to prior authorization restrictions or other utilization management?
Carriers are not allowed to require a member to obtain prior authorization for covered nonmedication, nonsurgical treatment modalities that may include restorative therapies, behavioral health approaches, or integrative health therapies, including acupuncture, chiropractic treatments, massage, and movement therapies. This may include a variety of approaches that use movement to promote physical, mental, emotional, and spiritual well-being, such as yoga, Pilates, or dance.
In addition, for all other medication or surgical treatments, carriers are not allowed to use any prior authorization, step therapy, or other utilization management controls, including, but not limited to, concurrent review or retrospective review, that are “more restrictive or extensive than the least restrictive or extensive utilization controls applicable to any clinically appropriate opioid drug. 3 See M.G.L. chs. 175, §47KK; 176A, §8MM; 176B, §4MM; 176G, §4EE
Can carriers charge higher cost-share amounts for non-opioid pain management medication than for opioid pain management medication?
The Division expects that no carrier will charge any higher copayments for non-opioid pain management medication than it charges for opioid pain medications.
How will I know which alternatives to opioids are available from my health plan?
It is required that Carriers “shall annually distribute educational materials to providers within their networks and to members about the pain management access plans developed” and “shall make information about the plans publicly available on their websites.” Consumers should contact their health plan for information and can also review the Division's listing of Carriers' Alternatives to Treat Pain.