At the 2008 National Conference of Insurance Legislators Spring Meeting in Washington, D.C., a panel led by Eric Goplerud, PhD (the director of Ensuring Solutions) and Dr. Larry Gentillelo (a trauma surgeon) reported that:  

• Alcohol and/or drug use problems are the nation’s third leading cause of preventable death—costing hundreds of billions annually in healthcare, legal, and other costs.

• SBI has proven effective in reducing alcohol and drug use in large studies involving over 460,000 patients—demonstrating a reduction in reinjury rates and DUI arrests. 

• Every dollar spent on SBI saves nearly four dollars in subsequent health care costs. 

• The American College of Surgeons requires all Level 1 trauma centers to provide SBI.

The panel also urged state lawmakers to:   

• Work with state officials to approve budget appropriations for the state Medicaid matching funds.

• Communicate with state medicaid directors, substance abuse and behavioral health departments to include the new Medicaid codes (H0049 and H0050) as part of state plan amendments.

• Continue efforts to repeal Uniform Accident and Sickness and Policy Provision Laws (UPPL) in their state.

BACKGROUND
The Uniform Accident and Sickness Policy Provision Law (UPPL) is a National Association of Insurance Commissioners (NAIC) model law adopted in 1947 and subsequently enacted into law by 42 states and the District of Columbia.  A provision in the model allows insurance carriers to exclude health insurance coverage for alcohol related injuries. NCOIL passed a resolution in support of repealing such outdated alcohol provision statutes in 2001, and reaffirmed its position in 2003.  Following arguments from NCOIL and other interested parties, the NAIC amended the model in June 2001 to prohibit insurers from using patient alcohol or drug use for denial of a health insurance claim.     

UPPL and Intoxication Exclusions
UPPL, and other state policies that allow intoxication exclusions in health care insurance, permit insurers to deny coverage to people injured while under the influence of alcohol or drugs. Exclusions can be used to deny payment to doctors and hospitals, discouraging substance use screening in trauma centers and emergency departments. Exclusions get in the way of identifying and helping people with substance use problems. On the one hand, doctors are afraid to do anything that might cause an insurer to deny payment. On the other, people with insurance policies that include exclusions usually don't know about it until a claim is denied.

37 states allow insurers to use intoxication exclusions: 28 states have laws that explicitly allow insurers to use intoxication exclusions: (Alabama, Alaska, Arizona, Arkansas, California, Delaware, Florida, Georgia, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, North Dakota, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Wyoming) Note: Illinois, Indiana, Maine, Oregon, and the District of Columbia passed laws prohibiting exclusions 2007.  

9 states implicitly allow insurers to use intoxication exclusions: (Massachusetts, Michigan, Minnesota, New Hampshire, New Mexico, Oklahoma, Utah, Vermont, and Wisconsin) The 9 states that implicitly allow intoxication exclusions do not have a specific law related to exclusions. Instead, courts have ruled that, in the absence of explicit laws, insurance companies can sell policies that use exclusions to limit liability. Court rulings vary by state, with some being more lenient (requiring proof only of alcohol or drug use prior to injury) and others being more strict (requiring proof of a causal relationship between the use of alcohol or drugs and the injury).  

13 states and the District of Columbia prohibit insurers from using intoxication exclusions: (Connecticut, Colorado, Illinois, Indiana, Iowa, Maine, Maryland, Nevada, North Carolina, Oregon, Rhode Island, South Dakota, Washington, and the District of Columbia)

What are the consequences of intoxication exclusions? Intoxication exclusions are a classic case of unintended consequences. Intended to discourage drinking and drug use, intoxication exclusions have actually allowed drunk drivers to escape detection. Between 85 percent and 96 percent of drunk drivers involved in a crash avoid detection if they are transported to a trauma center. Intended to save insurance companies money, intoxication exclusions have actually contributed substantially to almost $20 billion in annual alcohol-related health care costs. At the time of trauma center admission, 40 percent of injured patients have a positive blood alcohol concentration (BAC). But, because intoxication exclusions permit insurers to deny coverage for injuries suffered under the influence, many medical providers are reluctant to test injured patients' BAC. This limits the number of patients who receive brief counseling in emergency rooms. Individuals receiving brief interventions have 48 percent fewer readmissions to the hospital. And for every dollar spent on alcohol counseling for injured patients, hospitals can expect to save almost four dollars.  

What is the rationale for prohibiting intoxication exclusions? Prohibiting exclusions would: Increase the likelihood that drunk drivers will be detected. Help prevent repeat drunk driving incidents. Reduce the costs of health care. Provide the opportunity for treatment of substance use problems at the time when treatment can be most effective.  

Who supports the prohibition of intoxication exclusions? The National Association of Insurance Commissioners (NAIC voted unanimously in 2001 to recommend prohibiting intoxication exclusions). Other groups that support eliminating exclusions include:

• National Conference of Insurance Legislators (2001)

• American Medical Association (2003)

• Mothers Against Drunk Driving National Commission Against Drunk Driving (2001)

• American College of Emergency Physicians American Public Health Association (2004)

• American Bar Association (2005)

• American College of Surgeons (2006)

Thanks to Jordan Estey at NCOIL for the summary of the panel discussion at the 2008 Spring Meeting.