The Patient Protection and Affordable Care Act (Obamacare), passed in 2010, provides that most insurers must cover essential health benefits as part of their services. The National Academy of Medicine (formally known as the Institute of Medicine) reports that this means that most basic benefits, such as emergency services, laboratory services, pediatric services, vision care, behavioral health treatment, mental health treatment, and substance use disorder services, and a number of other services fall under this title.
The Mental Health Parity and Addiction Equity Act that was passed in 2008 requires that insurers provide the same level of benefits for behavioral healthcare services that they do for primary care services. The Affordable Care Act amended this act to ensure that both private and group insurers provided these services.
Alcohol Use Disorder Treatment Coverage
Some general principles regarding insurance coverage for alcohol use disorders include:
- Outpatient treatment: The cost of outpatient treatment for alcohol abuse is typically covered to some extent.
- Residential treatment: Inpatient treatment services are often covered in part but every expense on a residential or inpatient unit may not be fully covered by insurance. It is prudent to check exactly what services related to inpatient alcohol use disorder treatment are covered and what services an individual will have to pay out of pocket before choosing between an inpatient and outpatient treatment program.
- Withdrawal management: Most health insurance plans cover withdrawal management (medical detox) treatment to some extent.
- Therapy: Most insurance programs will cover the cost of therapy to some extent.
- Medications: Insurance programs differ on how the cost of medications for alcohol use disorders is covered.
- Copays: Most health insurance policies will require some form of out-of-pocket costs that are often calculated as a fixed rate or as a percentage of the entire cost. These are typically expressed as copays on one’s policy.
- Variations in coverage still exist: There is no standard coverage policy used by all commercial health insurance companies. Actual coverage depends on the specific company and plan as well as the state a person lives in.
The services covered by commercial health insurance plans are determined by a number of different factors. Most often, these factors include the following:
- The medical necessity of the treatment for the specific condition: Sometimes, the referral source can make a big difference. Insurance companies may give more consideration to requests for treatment services when they are given by a physician. Physicians are often considered to be more reliable sources regarding the medical necessity of the specific treatment than therapists, social workers, and other mental healthcare workers or addiction treatment workers.
- Empirical evidence: The status of empirical evidence for the treatment will affect whether it is covered or not. For example, a treatment that is not covered is ultra-rapid detox. This expensive treatment lacks empirical evidence regarding any advantages over traditional withdrawal management treatments, and it is associated with a number of dangers and medical complications.
- Medication coverage specifics: Regarding medication coverage, it depends if medications for treating alcohol abuse are covered at all in the specific policy and if the specific medication is listed in the policy as being approved for use. Medications that do not have sufficient empirical evidence for treating certain aspects of recovery may not be covered unless there is good justification for their use.
Readers who have insurance but are unaware of how much coverage they have for substance use disorder treatment should simply contact their insurance company’s customer service department and discuss the issue with them. If an individual is being rushed into emergency residential treatment for withdrawal management, the treatment program will contact the person’s insurance company and determine how much of the treatment will be covered. Because treatment providers are interested in getting paid, therapists will contact one’s insurance company to determine how much of the treatment will be covered under the specific policy. Clients can provide treatment providers with their insurance information, and providers can discuss paying for the specific treatment directly with the insurer.
Because insurance companies can no longer discriminate against individuals with co-occurring disorders, there are options for those who do not have insurance coverage. They can sign up for insurance on the Affordable Care Act’s website. In addition, if a person is not able to afford health insurance, they can apply for Medicaid. Medicaid programs typically cover at least part of the costs for treatment for alcohol use disorders and other substance use disorders, although individuals might be limited in regard to providers who will accept Medicaid.
A number of large commercial health insurance companies that are popular in the New England states have treatment options for substance use disorders. These include:
- Blue Cross/Blue Shield
- United Healthcare, Inc.
- Cigna Health Insurance, Inc.
- Aetna Health Insurance, Inc.