Insurance can be a tricky subject when it comes to addiction treatment. Many people are unaware of what their policy covers or which care providers are in-network. For a long time, insurance carriers were not mandated to provide mental and behavioral health care to their customers. Obamacare was created to counter this and make sure that everyone has access to quality treatment. Let’s dive into how it works.
Obamacare is not a specific insurance policy.
The 2010 Patient Protection and Affordable Care Act is better known under the name Obamacare because it was the conceptualization of U.S. President Barack Obama and passed during his first term in office.
It is a piece of legislation that attempts to guarantee a specific level of health care coverage to people in need of insurance. The passage of Obamacare amended previous legislation to make sure that private insurance plans and group insurance plans provide basic health care services, such as:
Often referred to as the Affordable Care Act (ACA), the legislation attempted to reform the health care system by providing all Americans with access to affordable health care. The above-listed services and others were deemed to be essential health benefits that all insurance policies should provide based on statues in prior legislation that were incorporated into the current bill.
Supporters of the ACA believe that millions of individuals who were not getting health care coverage before the law were able to get affordable and quality coverage following its implementation.
There are 10 primary health benefits that insurance plans must offer coverage for under Obamacare. The ACA provides guidelines for the minimal essential coverage for these 10 essential benefits. One of these essential benefits is coverage for the treatment of substance abuse.
Insurance companies must offer some level of substance abuse treatment in their policies, although there can be quite a bit of variability in how much of the cost of treatment is covered by each particular plan. Under Obamacare, the majority of available plans only provide partial coverage.
Obamacare prohibits anyone from being excluded from coverage due to a pre-existing condition.
Those who do not have insurance coverage can go to the Marketplace website and shop for insurance coverage they can afford that will best suit their needs.
Whether one gets a policy from the ACA Marketplace, is covered under an insurance policy from their employer, or has some other form of insurance, the amount of coverage under the policy, including for the treatment of substance abuse, is dependent on the policy. There is great variation in the amount of coverage insurance policies offered for different issues. Treatment for substance abuse is no different.
Insurance policies that offer more coverage are typically more expensive. Policies that have higher out-of-pocket costs will typically have cheaper premiums.
There are basic services that will most likely have some level of coverage under the vast majority of insurance policies, including Obamacare policies.
These services are usually covered when they meet the requirements for medical necessity.
Medical necessity is the concept that the intervention or treatment has research evidence to support its necessity to treat the condition. When treatments are deemed medically necessary, insurance companies are more likely to quickly approve them and to cover at least part of their costs.
Very often, the treatment that is the least expensive but still medically necessary will be the one the insurance provider will cover.
Anyone who is about to get treatment for a substance use disorder and attempting to get their Obamacare policy to cover part or all of the treatment cost should understand the following:
While there are significant variations between policies, there are general guidelines to consider.
Many insurance policies have a limit or ceiling on the number of treatment sessions that will be covered, such as a set number of therapy sessions per quarter or year, or the length of time one can remain in residential or inpatient treatment.
Customer service representatives are happy to help policyholders who have questions about their specific coverage.
Treatment providers, such as rehab centers, therapists, hospitals, and others, will typically have an intake process where the presenting problem will be assessed, and the treatment provider will contact the insurance company to determine the amount of coverage the person has for that issue. Any uncertainties about coverage can be cleared up between the treatment provider and the insurance company.
When in doubt, get a referral from a physician for treatment. This referral goes a long way in getting maximum coverage for treatment.
Everyone should be prepared to pay some out-of-pocket expenses, such as copays and deductibles, regardless of the specific insurance policy they hold.
For a free consultation and assessment, give us a call at (855) 905-0828 or contact us online today.
(April 2018). National Helpline. Substance Abuse and Mental Health Services Administration. . Retrieved January 2019 from from from https://www.samhsa.gov/find-help/national-helpline
(2013). The Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition. American Psychiatric Association. from from https://books.google.com/books?hl=en&lr=&id=-JivBAAAQBAJ&oi=fnd&pg=PT18&ots=cdRR23NJxb&sig=hqcxV0blNxO5C8MW8Cir3ZUxtVg#v=onepage&q&f=false
(2019) 2019 Open Enrollment is Over: Still Need Health Insurance? Healthcare.gov. Retrieved January 2019 from from https://www.healthcare.gov/?utm_campaign=031115_hhs_hcg_share&utm_medium=social&utm_source=hhs_healthcare&utm_content=031115_hhs_hcg_share_tablink
(N.D.) Mental Health & Substance Abuse Coverage. Healthcare.gov. Retrieved January 2019 from from from https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
(N.D.). Patient Protection and Affordable Care Act. Healthcare.gov. Retrieved January 2019 from from from https://www.healthcare.gov/glossary/patient-protection-and-affordable-care-act/