Alcoholism and drug addiction may not seem as serious as cancer or heart disease, but for the countless people they affect, health insurance can mean the difference between kicking the habit and ending up sick and hopeless.
Drug abuse and addiction is expensive to America, with the Office of National Drug Control Policy pegging the cost at $200 billion in health care, criminal justice, legal and lost productivity in 2007, way before the opioid crisis plagued the nation. Meanwhile, according to the National Survey on Drug Use and Health, 21.5 million American adults were fighting some form of substance abuse in 2014.
While the Affordable Care Act certainly has critics and is under attack from the Republican-led Congress, it has helped people with addictions get the treatment they need. “On the marketplace side, the ACA helped strengthen rules that require most plans to cover mental health and substance abuse services at the same level as they do for physical health,” says Peggy Bailey, director of the health integration project at Center on Budget and Policy Priorities, the District of Columbia-based research and policy institute. “[Prior to the ACA] on the Medicaid side, if your primary condition was substance abuse disorder, that wasn’t enough to qualify you for Medicaid.”
[Read: Why Do You Need Health Insurance?]
Obamacare Paves the Way for More Coverage
Under the Affordable Care Act, which is still the law despite efforts to repeal it, substance abuse is considered one of the essential health benefits. That means insurers have to offer coverage for it in their marketplace health insurance plans.
Paul Rooney, vice president of small business, individual and family products at eHealth — the Mountain View, California, online health insurance exchange operator — says the services covered for people suffering from addiction include behavioral health treatments such as counseling, mental and behavioral health inpatient services, and inpatient and outpatient substance abuse treatment.
What’s more, Rooney says that under the Affordable Care Act, patients can’t be turned down because of a prior condition, with coverage kicking in on day one under any new plan. Insurance companies are prevented from placing any annual or lifetime coverage caps on substance abuse treatments, although deductibles, copayments and other cost-sharing expenses will apply, Rooney says. The Affordable Care Act also expanded the parity law to cover substance abuse, which means insurance plan providers can’t impose restrictions on addiction services that are more restrictive than medical and surgical services.
[Read: 6 Health Care Expenses Medicare Won’t Pay For.]
Limitations Still Abound
Still, Rebecca Farley David, vice president of policy and advocacy at the National Council for Behavioral Health — a District of Columbia-based nonprofit — says there are still limitations to the coverage that creates roadblocks for people looking for help depending on what state they live in. That’s because it’s up to each state to determine what essential benefits are covered in the plan, which has led to some states offering less comprehensive coverage than what addiction experts would like. David adds that when it comes to substance abuse care, there’s a much higher use of out-of-network providers than there is on the medical and surgical side of things. That makes it harder and costlier to find a provider in-network. “In an ideal world, we would love to see more comprehensive coverage benefits,” David says.
Help for Uninsured
Consumers who currently have health insurance or already purchased their plan for 2018 don’t have to worry about being shut out of addiction treatments.
Those who missed the deadline and are uninsured must have a life event to purchase coverage on the marketplace exchanges outside of open enrollment, or they’ll need to wait until next year. Such life events under the ACA include getting married, losing a job, having a baby and becoming a divorcee.
[See: How to Pick a Health Insurance Plan.]
There are options for people who end up uninsured and need help with an addiction. “Significant mental health resources are available both at the local and national level — even for those without health insurance,” Rooney says, noting that the free and low-cost services vary from one state to the next. On the national level, Rooney points to the Health and Human Services Department, which offers a list of free clinics around the country. He says that when someone is shopping for health insurance with an eye toward addiction treatment, it’s important to know if you’ve met your full deductible before the coverage kicks in. If the deductible will be an issue, Rooney suggests opting for a plan that has substance abuse treatment with only a copayment and coinsurance.
“Keep in mind that coverage may differ for inpatient and outpatient care under the same plan, so look at the benefits summary to make sure you understand how these may be paid differently by the insurance company,” Rooney says. “If you have a specific provider in mind for substance abuse or mental health care treatment, make sure that they are part of the plan network before you enroll.”
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What to Know About Health Insurance for Addiction Issues originally appeared on usnews.com
