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Is Drug Rehab Insurance Affected by the Affordable Care Act?

Is Drug Rehab Insurance Affected by the Affordable Care Act?

Entering treatment often means overcoming obstacles. For some figuring out how to pay for rehab tops the list even though allowing an addiction to continue is far more costly. According to the National Institute on Drug Abuse (NIDA), the economic burden to the United States for addiction is twice that of any other disease affecting the brain including Parkinson’s and Alzheimer’ Disease. Personal costs, including the toll addiction takes on relationships, mental health and career satisfaction, are inestimable.

Sadly financial considerations are one factor that prevents people from seeking help. The Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health reports that of the 23.5 million persons age 12 or older who needed treatment for an illicit drug or alcohol abuse problem in 2009, only 2.6 million, which is just 11.2%, received it at a specialty facility. One way the government is seeking to remove this barrier is through a comprehensive health insurance reform called the Affordable Care Act.

Affordable Care Act Basics

According to the Office of Drug Control Policy, goals of the Affordable Care Act (ACA) include the following:

  • To make health insurance available to many more people
  • To lower health care costs
  • To guarantee more health care choices
  • To enhance the quality of health care for all Americans

The ACA includes substance use disorders as one of the ten elements of essential health benefits. This means that all health insurance sold on Health Insurance Exchanges or provided by Medicaid to certain newly eligible adults starting in 2014 must include services for substance use disorders.

By including these benefits in health insurance packages, more health care providers will be able to offer and be reimbursed for these services, resulting in more individuals having access to treatment. The specific substance abuse services that will be covered are currently being determined by the Department of Health and Human Services.

Parity Law: Your Legal Rights

Millions of Americans with substance use disorders do not have adequate insurance protection against the costs of treatment for mental and substance use disorders. The Mental Health Parity and Addiction Equity Act (MHPAEA) makes it easier for them to get the care they need by prohibiting certain discriminatory practices that limit insurance coverage for behavioral health treatment and services. Prior to MHPAEA and similar legislation, insurers were not required to cover mental health care shortcoming that limited many people’s access to rehab.

According to the MHPAEA insurance plans that cover substance use disorders are required to offer coverage for those services that is as generous as the coverage for medical/surgical conditions. This requirement applies to the following:

  • Co-pays, coinsurance and out-of-pocket maximums
  • Limitations on services utilization such as limits on the number of inpatient days or outpatient visits that are covered
  • The use of care management tools
  • Coverage for out-of-network providers
  • Criteria for medical necessity determinations

Coverage that the MHPAEA does not require insurance plans to offer include the following:

  • Coverage for substance use disorders in general
  • Coverage for specific substance use disorders
  • Coverage for specific treatments or services for substance use disorders

Professional recovery centers usually offer free help determining coverage and benefits. Information they may request from a caller inquiring about treatment includes the following:

  • Is detox needed?
  • Have you attempted outpatient treatment?
  • What is your desired length of stay?

It is important to keep in mind that this parity laws may not apply to smaller health insurance companies or individual insurance plans.

Medical Necessity: Proving Your Case

Most insurance companies approve or reject a claim for treatment based on the principles of medical necessity. According to the American Society of Addiction Medicine (ASAM), several criteria that prove a service is medically necessary include the following:

  • The requested treatment services are required to diagnose or treat a suspected or identified illness or condition.
  • Scientific evidence proves that the requested treatment is effective for the condition.
  • The requested treatment is required for more than just the convenience of the requester or provider (meaning, for example, that though you might find it more comfortable to go away to rehab, unless you can prove that you need it for a medical reason, you will likely get coverage only for outpatient treatment).

Meeting the following preconditions generally results in a claim approval for residential treatment:

  • Your withdrawal symptoms can be managed at the requested level of care.
  • You are cognitively able to participate in a treatment program and have no other medical problems, which preclude your ability to participate.
  • You show evidence that you want treatment and are motivated to work toward recovery.

Most plans require that you meet at least one of the following criteria:

  • The severity of your self-harm or risk taking behaviors present a serious threat to yourself or to others, and these self-harm or risk taking behaviors can’t be effectively managed outside of a 24 hour facility.
  • You have acute medical problems that make it difficult or impossible for you to stay abstinent outside of a residential environment.
  • Your substance abuse is causing severe problems in at least two domains of life such as school, work, family, social relationships, or physical health
  • There is evidence that a lower level of care (such as previous attempts within the last 3 months at a lower level of care, like an intensive outpatient program) would not help.
  • There is evidence that without residential treatment your condition will worsen.
  • There is evidence that residential treatment should ameliorate symptoms.
  • Your current living arrangements are dysfunctional and endanger your recovery progress and there are no other clinically appropriate or available living arrangements.

Although the ASAM identifies only these three core components, most insurance companies add a fourth component to the decision-making process, namely that the requested treatment is not more costly than any other treatment that is as likely to produce an equivalent result.

Recovery from Addiction

If you or someone you love struggles with substance abuse, help is available. Admissions coordinators at our toll-free, 24 hour support line can guide you to wellness. You don’t have to feel alone when help is just one phone call away. Start your recovery now.