Insurance

Does insurance cover rehab? The short answer is: “It depends.”

Concerns about paying for rehab pervade. According to the 2008 Survey on Drug Use and Health (NSDUH), the most common reason substance abusers do not enter rehab is a lack of health insurance, insufficient insurance coverage, or other financial limitations related to paying for treatment services. Despite these concerns, substance abusers do manage, through various efforts, to enter rehab. A national review of admissions to rehab in 2007 showed that 60 percent of those who entered rehab had no health insurance at all.

The high level of rehab admissions, even in spite of the lack of health insurance, is quite a feat in light of the fact that a NSDUH study found that in 2013, while 22.7 million substance abusers needed rehab for illicit drug or alcohol use, fewer than three million actually received treatment. Substance abuse is always taking a gamble on your health, and not seeking treatment is equivalent to doubling down. If substance abusers are finding their way into treatment despite a lack of insurance, it’s because they or their loved ones realize the severity of not entering rehab.

Information for the Uninsured

The Affordable Care Act (ACA) is changing the face of insurance coverage in America. This national health care plan was instigated, in part, by longstanding concerns about many Americans suffering from a lack of health insurance coverage. As an indication of the lack of coverage in America pre-ACA, the 2012 National Health Interview Surveyrevealed the following information:

• About 45.2 million Americans under age 65 were uninsured.
• In the under-65 group, 61 percent had private insurance.
• In the 18-64 age group, 20.9 percent were uninsured.
• In the same group, 64.1 percent had private insurance and 16.4 percent relied on a public health plan.

Today, anyone who is not insured may benefit from ACA. The federal government operates Healthcare.gov where Americans can connect with a health care plan navigator and learn important information about coverage. Based on personal information, including income, a navigator works with a client to find affordable private insurance options in the “marketplace.” In some qualifying cases, where income is low enough to meet the necessary guidelines, a navigator can help a client to apply for state Medicaid benefits (public health insurance).

An alternative source of health insurance is employment-based insurance and dependent benefits (such as coverage through a spouse or parent employee). A substance abuser who is uninsured is well advised to explore all options and do a cost comparison. In the case of employment-based or other insurance options, it is best to contact the carrier directly. In the alternative, a human resources representative (at the employer’s office) may work as an intermediary and be a source of helpful information.

If the substance abuse has lapsed into a state of health that makes self-help impossible, a loved is best advised to contact any potential private insurance carriers and also a health care navigator. The loved one will want to learn if there is a procedure whereby he or she can act on behalf of the person in need of rehab services to apply for insurance (especially if the substance abuser can be the loved one’s dependent for private insurance purposes).

ACA

The ACA includes an agenda to integrate substance abuse treatment into the mainstream health care system. As A. Thomas McLellan, former Deputy Director of the White House Office of National Drug Control Policy points out, if insurance companies treated diabetes like substance abuse then only the latter stages would usually be covered, when the person had already suffered severe kidney damage or loss of vision. McLellan makes the analogy, in part, because there are an estimated 23 million Americans who abuse or are dependent on drugs, which is similar to the number of adults who suffer from diabetes.

Also, McLellan’s experience is that health insurance for substance abuse is often triggered during the advanced stages, and from a care perspective, this is unnecessary late. But ACA is helping to change the state of health care coverage for substance abuse.

Under the ACA, improvements in the substance abuse treatment area include:

• Substance abuse treatment is part of the primary care system and has a prevention focus.
• Treatment for substance abuse is considered an “essential service” and therefore health plans must include some form of coverage.
• Health plans are required to treat different phases of substance abuse, including the early stages.
• Medicaid and Medicare coverage of doctor visits (including evaluation, screening, and medication), home health visits, clinic visits, alcohol and drug testing, and family counseling (among other services).

As McLellan notes, the ACA not only improves Medicaid and Medicare coverage of substance abuse, but also impacts private insurance as this industry often looks to the federal system as a model. In addition, the more substance abuse treatment coverage develops, the more financial incentive pharmaceutical companies will have to develop relevant treatment medications. Substance abuse treatment has found an ally in ACA, which has the potential to stimulate growth in the field of rehab services.

Medicaid

For substance abusers with active Medicaid coverage, it is important to note that benefits vary from state to state. According to the State Profiles of Mental Health and Substance Abuse Services in Medicaid, federal rules control the types of coverage that states can offer in their Medicaid programs. Some services are mandatory (every state will include them) while others are optional (the state may or may not provide the benefit, so it is best to learn more).

As of the time of the report, the following substance abuse treatment services were mandatory state to state:

• Hospital services, inpatient and outpatient
• Physician services
• Federally qualified health center services
• Services at rural health centers

Although ACA has impacted the current Medicaid and Medicare benefit structure, as of the time of the report, the following benefits were optional offerings for states (and all states chose to provide at least one optional service):

• Rehab services
• Sessions with licensed practitioners who are not physicians, such as a Certified Alcohol and Substance Abuse Counselor (CASAC) or psychologist
• Case management
• Community-based and at-home services
• For those under age 22, inpatient hospital services

For Medicaid recipients, one of the earliest steps in finding treatment will be to locate a rehab center that accepts Medicaid. The rehab center will likely have information on the specific terms of Medicaid coverage, but it is always a good idea to double check with Medicaid services (speak with a health care navigator or visit the official Medicaid site). Remember, health insurance coverage is always governed by the specific terms of the health insurance contract. Coverage should not be left to interpretation; in non-emergency cases, it is always advisable to be as clear as possible about benefits before receiving services.

Private Health Plans

As discussed, a health care navigator can assist Americans to locate a suitable insurance plan in the “marketplace.” The private plans in the Marketplace are required to provide a substance abuse treatment benefit. Services include behavioral support (such as psychotherapy). Specific benefits for behavioral health vary from state to state and plan to plan. Consumers can learn more about the details of plans before they select one.

Employment-based private health plans, also known as group health insurance plans, generally cover substance abuse treatment under mental and behavioral health services. While the ACA has impacted private health plans, coverage gaps may still exist. However, the Mental Health Parity and Addiction Equality Act (MHPAEA) includes provisions for group health insurance plans.

The MHPAEA applies to group health care plans that have more than 50 members. The MHPAEA does not require insurance companies to have a mental health benefit, but if the plan elects to include this coverage, there are certain conditions that must be met. For instance, the coverage for physical health issues cannot be greater than that for mental health issues. Further, group health plans that fall under the MHPAEA cannot carry separate deductibles for mental health care nor limit the number of visits or charge higher copays compared to services for physical issues.

Some individual health insurance plans (e.g., purchased individually, not based on employment, and not publicly subsidized) cover substance abuse treatment. Although the MHPAEA does not apply, there may be state laws that influence terms of coverage related to substance abuse treatment. Members of individual insurance plans are best advised to contact the carrier directly to learn the specific terms of coverage. It is important to provide as much relevant information as possible about the type of rehab services sought. For instance, some plans may cover alcohol treatment but not cigarette smoking cessation programs. Also, an insurance company may not cover court-ordered treatment unless, for instance, the substance abuse passes the insurance provider’s medical necessity standards. When it comes to insurance, it is always best – whenever possible – to be safe than sorry. One of the keys to recovery is not being stressed about the cost.

Hat tip and shout out to dualdiagnosis.org