Using Insurance or Obamacare for Drug Treatment: A How-to Guide

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.

What Is Obamacare?

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:

  • Laboratory services
  • Pediatric care
  • Vision care
  • Emergency treatment services
  • Mental health and behavioral health care

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.

How Does the ACA Affect Treatment for Substance Abuse?

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.

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Ready to Get Your Life Back? Call Today and Talk to an Addiction Specialist!

What Must Plans Provide?

The plans marketed through the ACA Marketplace must:

  • Provide some level of coverage for behavioral health treatments, such as therapy
  • Provide some level of coverage for behavioral health and mental health inpatient treatment services
  • Provide some level of coverage for substance use disorder treatment

Obamacare prohibits anyone from being excluded from coverage due to a pre-existing condition.

What Is Covered in Policies?

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.

Intensive Outpatient

What Basic Substance Abuse Treatment Services Are Most Likely Covered?

There are basic services that will most likely have some level of coverage under the vast majority of insurance policies, including Obamacare policies.

  • Medical detox or withdrawal management is typically covered to some extent under most insurance policies. The policy may not cover services that are not necessary for the treatment of withdrawal symptoms, such as facility amenities, or that do not have research evidence to justify their use for the treatment of withdrawal. Rapid and ultra-detox may not be covered, as these services lack sufficient research evidence.
  • Inpatient and residential treatment services are typically covered to some extent under most policies.
  • The cost of most prescribed medications will be covered to some extent, particularly if the medications directly address substance abuse or some other mental health issue.
  • Formal therapy and counseling services (both individual and group) are typically covered to some extent; however, complementary or alternative therapies may not be covered.

These services are usually covered when they meet the requirements for medical necessity.

What Is 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.

Struggling with addiction? Let our treatment specialists help you now!

Struggling with addiction? Let our treatment specialists help you now!

Other Policy Specifics

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:

  • There are often out-of-pocket obligations that are stated in the insurance policy. Policyholders must cover these costs themselves, and the costs include copays, deductibles, and other expenses.
  • Policyholders must ensure the treatment they get has been approved by their provider. For instance, acupuncture, yoga classes, and luxury amenities are often not covered under insurance policies even though many rehab providers advertise them.
  • Policyholders must ensure that the proper referral for treatment is provided to the treatment provider. Some insurance plans require a referral from a physician for certain types of interventions, such as inpatient medical detox, whereas other interventions may only require a self-referral or a referral from nonmedical personnel.

What Are Other Important Issues?

While there are significant variations between policies, there are general guidelines to consider.

  • Certain types of addictions may not be covered under most insurance plans. For example, sex addiction is not a formal DSM-5 diagnosis so its treatment may not be covered the same way that substance addiction is covered. Make sure the specific diagnostic reason for treatment is covered under the policy.
  • Treatment for most drugs of abuse is covered to some extent under most insurance policies. However, certain types of treatments, such as inpatient medical detox for a tobacco use disorder, would most likely not be covered or would only be covered in extreme circumstances. If the treatment does not seem to fit the problem, ask about coverage.
  • It is much easier to get coverage approved for outpatient treatment than for inpatient treatment. Many insurance policies have specific guidelines regarding conditions that must be met for inpatient substance abuse treatment to be covered. In some instances, the person must have had prior unsuccessful attempts at outpatient treatment before inpatient treatment is approved.

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.

General Tips

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.


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