Inevitably, one of the first questions asked when discussing drug or alcohol rehabilitation programs is, “will my insurance company pay for it?”
If you have employer-provided or otherwise “private” insurance, you must contact your insurer to discover the exact terms under which your insurance covers your recovery journey. However, if you are one of the 12,000,000 (that’s 12 million!) Americans who receive their insurance coverage via the Affordable Care Act exchange (AKA ‘Obamacare’), you are in luck.
Mental and behavioral health services are essential health benefits
All plans must cover:
- Behavioral health treatment, such as psychotherapy and counseling
- Mental and behavioral health inpatient services
- Substance use disorder (commonly known as substance abuse) treatment
Your specific behavioral health benefits will depend on your state and the health plan you choose. You’ll see a full list of what each plan covers, including behavioral health benefits, when you compare plans in the Marketplace.
The above text, taken from Healthcare.Gov, shows us that It is a requirement of the Affordable Care Act that providers pay for at least some of your treatment and recovery process. However, that’s not the end of the story.
The majority of plans on the Affordable Care Act exchange are high deductible, meaning you must hit a dollar amount spent per calendar year before you gain the benefit of your insurance coverage.
Additionally, you will be responsible for a “copay” or “co-insurance” even after you reach this deductible limit. The cap for “max out of pocket” is often quite high for more economically priced plans, so that “copay” will likely be an ongoing part of your recovery process.
However, not all the news is dour. Let’s refer to Healthcare.gov again:
Pre-existing mental and behavioral health conditions are covered, and spending limits aren’t allowed
- Marketplace plans can’t deny you coverage or charge you more just because you have any pre-existing condition, including mental health and substance use disorder conditions.
- Coverage for treatment of all pre-existing conditions begins the day your coverage starts.
- Marketplace plans can’t put yearly or lifetime dollar limits on coverage of any essential health benefit, including mental health and substance use disorder services.
The pre-existing condition language tells us that the insurer cannot attempt to avoid the responsibility of assisting your recovery journey by stating that your disease arose before you were covered under their policy. The second point states that the insurer cannot make you wait to seek treatment for your sickness – your coverage begins as soon as the policy is in effect. Lastly, they cannot cap their expenditures on your rehabilitation, as opposed to say, limiting your number of counseling sessions.
However, there are more concerns at hand than just financial. To get the treatment you need, we must consider the following:
Depending on the care you need, you may need a referral from a doctor for the care to be covered by insurance. HMO plans often have this requirement, and your PCP (Primary Care Provider) would have to evaluate your situation and provide referrals accordingly for you to have your care covered by your insurance.
PPO plans, on the contrary, will often allow you to simply seek the care you require without having to have your PCP approve it. If you have any questions whatsoever, contact your insurer on the phone number on your card.
Another consideration is the nature of your addiction. Under the ACA, coverage for alcohol, opioids (prescription and otherwise), and recreational drugs is mandatory. However, coverage for other addictions, such as behavioral (for example, a social media addiction, or online gaming addiction) may not be – consult with your doctor and insurance company for clarification.
What about Medically Assisted Treatment (MAT?)
Medically Assisted Treatment, or MAT, is the use of ‘maintenance’ drugs such as Suboxone and Buprenorphine (or Subutex), combined with various types of therapies to prevent relapses. Some treatment plans are covered by ACA insurance, and some are not. Again, the best way to avoid unexpected financial hardships during your treatment is to consult with your doctor and your insurance company.
Will my insurance company approve my treatment?
When your doctor refers you to a course of treatment, your chart is submitted, along with his or her recommendation, to the insurance company, where their internal adjustors make a decision to cover the claim or deny it. If you are denied the claim, immediately demand a review of the decision. If their denial is especially egregious, they may cave immediately.
If they do not, then your claim is submitted to a doctor employed by the insurance company to decide if the plan is medically necessary. This is what is known as an “Internal Review”. If the insurance-employed doctor upholds the rejection of the claim, do not fret. You should then immediately demand an outside doctor review the claim, in what is known as an “External Review”.
Some insurers have so-called “Fail First” policies, to where you must have relapsed on a cheaper outpatient program before they will honor a claim for an inpatient program. Outpatient programs are often quite successful, so unless your living situation is untenable in regards to your recovery journey, you may find that these are a better option than going to an inpatient rehabilitation center.
These processes can often be avoided if your referring doctor is familiar with the correct wording and verbiage to use in your chart to impress upon the company the debilitating and time-sensitive nature of your addiction. Your doctor can be a powerful ally if they are experienced in dealing with often stingy insurance companies.
Your ACA plan does cover rehabilitation services. The amount of coverage varies based on your plan. You will likely face up-front costs (your deductible) before your insurance provider steps in. Some types of addiction may not be covered, but major chemical dependencies are (opiates, alcohol, so-called ‘recreational drugs’).
Some providers will require a referral, and some will not. Verify with your doctor and insurance company about what is covered and what is not. If your treatment plan is denied – immediately challenge the denial. If the internal review is denied, challenge again for an external review.
It may seem complicated, but by being proactive and fighting for yourself you have a good chance of getting rehabilitation programs to be covered by your ACA plan.