New healthcare reforms emerged in the United States in the early 2010s. These reforms aimed to provide affordable and accessible health care insurance coverage to previously uninsured Americans. According to the Journal of Substance Abuse Treatment, the Patient Protection and Affordable Care Act, often referred to as Obamacare, was expected to provide insurance coverage to more than 5 million people with addiction and mental health disorders who were previously without coverage.
Health insurance plans are available from state marketplaces online, with low-income households receiving additional subsidies to make coverage more affordable. According to the AMA Journal of Ethics, households with incomes that are less than 400 percent of the federal poverty level qualify for federal subsidies under the ACA.
Is Rehab Covered?
Rehab is covered by the Affordable Care Act (ACA). According to Obamacare Facts, substance abuse disorders are covered on Obamacare health insurance plans as one of the 10 essential health benefits. This means that all health insurance plans that meet the Affordable Care Act’s guidelines for minimal essential coverage include coverage for substance abuse treatment.
However, it should be noted that most of these plans cover these treatments as part of a cost-sharing plan where the insured needs to pay some of the costs associated with treatment, whether it be inpatient rehab or outpatient addiction treatment. Some other health services, such as yearly well woman visits, are covered at the 100 percent level. This is not usually the case for rehab programs.
Each plan available on the marketplace offers different coverage availability and rates, so it is important to understand exactly what you are signing up for to make sure you choose the right plan for your specific needs. You want to find the plan that provides the most coverage for the services and medications you need.
Many of the health insurance plans available on the health insurance marketplaces have a high deductible. This means that you will have to pay the deductible first before coverage is provided under the plan. Before enrolling in a particular addiction treatment program, clarify exactly what your out-of-pocket costs will be. Generally, a representative for the program can serve as a liaison with your insurance company, helping you to determine your exact level of coverage.
What Obamacare Ensures In Health Insurance Coverage
According to HealthCare.gov, mental and behavioral health services must be covered by health insurance providers, including pre-existing conditions.
- All plans must cover behavioral health treatment, inpatient services for both mental and behavioral health, and substance use disorder treatment
- Health insurance plans are not allowed to charge more because of a pre-existing condition, such as a substance use disorder.
- Marketplace health insurance plans cannot put yearly or lifetime dollar limits on substance use disorder services.
- Any limits placed on care cannot disproportionally impact substance abuse coverage and must be equal to regular health coverage.
Factors That Affect Coverage
There are some factors that may impact the type of coverage that is covered by Affordable Care Act health insurance plans. Prior attempts at rehab should not make any difference from an insurance standpoint; however, depending upon the type of insurance plan (HMO or PPO), you may be required to get a referral from your primary care doctor to receive treatment for substance use disorders.
Additionally, not all types of addictions are covered by health insurance. Most substances that are known to be addictive are covered, including opioids, alcohol, and various recreational drugs. However, the medical community’s understanding of addiction constantly involves. Some other addictions, such as certain behavioral addictions, may not be covered. It is worth checking with your primary care physician, specific treatment center, and health insurance provider to determine what is covered.
Existing Treatment Limitations under the Affordable Care Act
While Obamacare does not specifically clarify a limit on the number of treatment days or sessions, there is a clear preference for individuals to try outpatient rehab first before inpatient care is recommended. According to Health Affairs, the Affordable Care Act prefers outpatient treatment that is integrated with many health disciplines. This means that health insurance companies want individuals to try less expensive outpatient options first before enrolling in inpatient care, which is generally more expensive.
Additionally, the ACA ensures treatment, not necessarily the proximity of the treatment to the policyholder’s home or the expediency of that treatment. Sometimes, you may need to travel for care based on your insurance coverage or wait for an appointment at a covered facility.
How a Person Can Determine Exact Coverage for Rehab Programs
Since your level of coverage for rehab services and how much you’ll pay in out-of-pocket costs vary widely by your specific health insurance coverage, it’s important to find out what’s covered. Here are some ways you can find out the specifics of your exact coverage:
- Call your health insurance company using the number found on the back of your insurance card.
- Check online at your health insurance company’s website or on gov.
- Ask your primary care doctor for in-network referrals for treatment programs.
- Contact treatment centers directly to see which insurance plans they accept. Once you’ve chosen a prospective treatment center, ask them to verify your coverage specifics.
According to the Archives of Physical Medicine and Rehabilitation, some medical specialties may face more demand than the available doctors and specialists can realistically treat. This may mean longer wait times for patients. To avoid long delays in treatment, find the names and contact information for a few different doctors, specialists, or rehab centers that are covered by your specific insurance policy.