Addiction is a disease. Getting individuals the necessary health care they need to prevail over substance abuse is central to the rehabilitation process, but a sticking point many encounter is the role of insurance. While strides have been made both in eroding the stigma of seeking mental health services and in increasing health insurance coverage, many complexities exist at their intersection.
A lot has changed in recent years, especially with Affordable Care Act reforms, and becoming knowledgeable on the basics of insurance will help you or a loved one make the most informed decision to seek treatment services. Nearly 23 million Americans (8.6 percent of the population) needed treatment for substance abuse in 2013, according to the National Institutes of Health, but just 2.5 million sought help.
It’s crucial to clear up the reality of insurance and substance abuse treatment, particularly if ambiguity is preventing you or a loved one in any way from seeking treatment. Here’s what you need to know:
ACA requires coverage for substance abuse treatment
Before the Affordable Care Act, health care services for substance abuse were infrequently covered under both public and private insurance policies, according to a review of the ACA’s effects published in the American Journal of Public Health. All that changed with the reforms the comprehensive legislation enacted, which extended access to substance abuse treatment through four means:
- General reduction of the uninsured population.
- Regulatory changes codified substance abuse services as “essential benefits” all government-backed plans must offer.
- Extension of legislation that ensures such services are provided “in a no more restrictive way than medical and surgical services.”
- Promotion of care coordination between primary providers and substance abuse treatment providers.
All insurance plans available on the federal or state marketplaces must cover mental health and substance abuse services including:
- Behavioral health treatment, like psychotherapy and counseling.
- Mental and behavioral health inpatient services.
- Substance use disorder treatment.
Another impact of the ACA is protection for pre-existing conditions. Before the law, insurers had wide latitude in denying coverage or charging more if a consumer had previous or current conditions, including substance abuse disorders. Those practices were ended with the ACA, which mandates that insurers extend coverage to consumers regardless of their medical histories, meaning those seeking treatment services cannot be discriminated against.
“The ACA expanded Medicaid to help increase insurance coverage of addiction treatments.”
Policies include lots of details and minutiae
With all that said, you will still have to scrutinize your insurance policy to understand the exact specifics that apply to your coverage. Even though the ACA enshrined broad protections and reforms, states can still control the definition of what substance abuse disorder services entail, as well as other insurance particulars. For instance, the ACA expanded Medicaid, the government insurance program intended for low-income consumers, to help increase insurance coverage of addiction treatments. However, not all states have gone along, so it’s incumbent on you or a loved one to check that status before taking any other action.
Beyond coverage particulars, scanning the policy for all the fine print is an essential task. Focus on the financials first; this will help you understand exactly what your deductible is, what your copay might be and clear up any expectations for out-of-pocket contributions. Cross-reference the policy against what you know about the ACA and your health care rights to ensure everything is accurate. Also make sure to know what providers are considered in-network and which will accept your coverage.
Medication coverage varies between policies and states
Another aspect to consider about insurance is what pharmaceutical products the policy covers. Certain medications, like methadone or suboxone, are used to combat withdrawal symptoms and provide other therapeutic relief to some patients. There are other medications commonly prescribed in detox, in treatment and in recovery. However, differences regarding what drugs are covered exist on the policy and state levels. You may live in a state that did not expand Medicaid, or your insurance could impose refill caps or other limits. Being on top of all this information is central to ensuring substance abuse disorder services are rendered competently and cost-effectively.
There are also ways to receive the treatment needed even if you or a loved one does not have health insurance. While the options may be more expensive, they do exist, and emergencies occur. If you or someone you know could use more help understanding their insurance or are seeking addiction treatment services, contact Fairwinds Treatment Centers today. We can help walk you through the steps.