Types of Health Insurance Coverage
What type of health insurance coverage is available to me?
In 2014, over 91% of Americans were covered by a health insurance policy. Depending on the specifics of the plan, those with insurance can use that coverage for:
- Inpatient treatment in an approved rehab facility
- Outpatient rehab with an approved provider
- Medical detoxification, including medications
- Co-occurring disorders
- Follow-up therapy
- Medication-Assisted treatment
At one time, health insurance was once considered a luxury item. Individuals with tight budgets and low wages may not have had the resources necessary to buy any form of health care plan. Many would try to put away enough money to let them get medical care for life-threatening issues. Preventative care went unaddressed. In many cases, this meant addictions were left untreated. For those without health insurance, getting treatment for addiction was too expensive to even consider.
With the introduction of the Affordable Care Act, much of that changed. Now more individuals and families than ever have access to health insurance. In fact, according to the Kaiser Family Foundation, only 13% of people in the United States did not have health insurance in 2014. The remainder had the insurance coverage they needed to deal with health problems as they arose. Per the ACA, insurance plans include coverage for addictions and mental illness, although there are specifications and limits for families to get the benefits they need in a timely manner.
What Drug Addictions Are Covered By Insurance?
In a report on HealthCare.gov, insurance plans participating in the insurance marketplace have to provide care in ten healthcare categories, including addiction treatment. A number of health insurance plans follow the same rules, so they are able be sold in the marketplace at a future point in time. Most health insurance policies do not distinguish between drugs in “covered” and “non-covered” categories. If addiction treatment is included as a benefit, then rehab is provided to anyone who has an addiction, regardless of what that addiction was caused by. This model of health insurance is the same one used in order to treat other health conditions.
As an example, some individuals develop diabetes through overeating, while others develop issues due to gland or hormonal abnormalities. Health insurance policies that provide a weight-loss benefit do not cover one category of weight loss while eliminating others. If this were the case, the plans would be much more expensive, as insurance companies would need to a complete medical history of each person requiring care, and the health plans would need to cover expensive tests in order to determine the root cause of the diabetes. By covering all treatments for diabetes, the insurance company can save money.
It is the same for addictions. Insurance companies do not want to cover sophisticated testing and interviews about the type of drugs used, how the drugs were made, where they came from, and what they were mixed with. Insurance plans can keep it simple by covering all drugs, assuming the plan offers an addiction care benefit.
Including addiction care can also help the states to keep down costs. Per a Public Broadcasting Service report, incarcerating an adult for a year can cost up to $37k, while providing residential treatment for addiction costs $14k. Plans managed by states might offer robust addiction c for all drugs simply because doing so could keep other costs in line.
Private plans might see benefits if addicted people don’t land in expensive emergency rooms due to addictions or overdoses. By providing care for addictions, they might also reduce the number of organ transplants they might need to cover. When it comes to savings, enhanced addiction treatment services for all drugs of abuse may be the way to go, and many insurance policies do just that.
This means that anyone with questions about what drugs are or are not covered by their insurance can reference this page and gain a clear understanding of their benefits. The information is a good first step for a person with addiction treatment questions.
According to the Affordable Care Act, insurance plans must provide a one-page summary of therapies and benefits, along with prices, per the U.S. Dept. of Health and Human Services.
Types of Facilities That Are Covered
There are more than 14,500 addiction rehab facilities for drug treatment in the US, per a National Institute on Drug Abuse (NIDA) report. Even though a health insurance plan may provide coverage for addiction treatment, not every facility may be included in the plan.
Some insurance carriers have individual contracts with providers of critical services. Per the contract, the providers agree to offer a type of care at a negotiated rate, and in return, the insurance carrier agrees to provide referrals to the providers. Mental Health America indicates that individuals with policies like this can ask their providers for the facilities or providers that the insurance company considers an in-network provider, but many treatment facilities that specialize in addiction are positioned to field questions about specific coverage. A call to a facility might provide answers to all of your questions question.
Some insurance policies offer benefits for types of treatment on the list. For example, KPCC in California indicates that Medi-Cal offers inpatient detox, residential treatment, and outpatient therapy for addiction. That includes a full spectrum of addiction treatment, all in a single plan. However, some insurance plans offer reimbursement for just a single type of treatment, and there may be a limit on the period of time that someone can take advantage of the treatment or service.
This is a good question to ask the health plan administrator, or families can ask the intake coordinator of an addiction treatment facility to do that research for them.
In addition to concerns about in-network coverage, there are issues about types of addiction treatment.
Addiction treatment centers can provide various types of rehab, including:
- Inpatient detoxification
- Outpatient detoxification
- Partial hospitalization program (PHP)
- Outpatient rehab
- Residential rehab
Are Mental Health Issues Covered?
The Affordable Care Act (ACA) did not only require the inclusion of addiction care. As part of the legislation, ACA plans were required to provide similar levels of care (parity) for mental health issues that they do for physical medical problems. This means policies that offer physician visits for a knee problem for $30.00 must also provide such visits for anxiety for $30.00. The service, and the cost, must be equal.
These parity laws apply to all different types of programs, including those purchased through health care exchanges, provided by employers, and those offered through Medicaid and CHIP, says The American Psychological Association.
Parity laws do not clearly state the types of mental health conditions plans must provide treatment for, but the guidelines are similar to those for drug addiction. If policies provide treatment for mental illness, they usually do not indicate that some conditions are covered while others are not covered. This would require an enormous amount of time and paperwork, and most insurance plan administrators do not have much of either of those to spare, so the plans just cover all of it.
It’s best to discuss the specifics of your plan with a plan administrator. However, the fear that mental health issues will not be covered because they are “bad” is generally not grounded in fact. Health insurance does not work that way.
Are Medication-assisted Treatment Programs Covered?
Medication-assisted Treatment (MAT) programs are designed for individuals who cannot achieve a reasonable level of functioning without their drug of choice, even if they have completed a rehab program. Chemical changes caused by the drug are often too severe in these individuals, and they need medications to correct the imbalances so they can live a life that’s free of the drugs.
Medication-assisted Treatment medications like buprenorphine, Suboxone, Vivitrol, and Antabuse are indicated for individuals with these types of chronic issues, but they can be costly. The goods news is, most of the data indicates that health insurance plans cover these drugs.
For example, most health insurance plans cover medication-assisted treatment medications drugs for people in recovery from addictions to heroin and other similar opioid-based drugs, says The National Alliance of Advocates for Buprenorphine Treatment. The organization does not indicate how many insurance plans offer this type of coverage or what the typical copayment might be, but they seem confident that most insurance policies do provide this benefit.
On the other hand, Medicaid and Medicare plans only cover MAT medications if the use is deemed critical for the ongoing sobriety of the individual in recovery, says The Substance Abuse and Mental Health Service Administration. If he or she is determined to be capable of healing without the MAT medications, benefits would not be provided under these plans.
It is made clear by these two opposing viewpoints that insurance plans can address addiction medication-assisted treatment programs very differently. That is why it is worth it for families in need of this type of care to ask about benefits, copayments, services, and therapies before they start to receive them. Some insurance plans may have extensive coverage while others do not.
At Clearpoint, the insurance verification process can take from a few minutes to several hours. Other addiction providers may require more or less time to verify benefits, and results can vary.
Using Your Insurance Benefits
Health insurance benefits were designed to make health care both accessible and affordable, and there is no stigma attached to asking for help. Individuals with addictions and insurance plans should use their coverage to the fullest extent in order to get the care they require to address their addictions and leave them behind. A great place to start is by talking to a plan administrator, but keep in mind that the staff at addiction treatment facilities can also be of great help.
In many instances, they can help you to navigate the intricacies of the insurance landscape and pave the way for smooth reimbursement of everything that you are due, leaving families with one less thing to worry about as they recover from the destruction of addiction.