Can Medical insurance be used to cover for treatment costs?

Substance Abuse Addiction Treatment is listed as an essential health insurance benefit under the Affordable Care Act (ACA). Accordingly, insurance companies are required to offer treatment for drug and alcohol dependency under even the most basic health plans. However, the type, cost, and specifics of treatment vary widely by an individual’s plan and in some cases, the state in which a person lives. The essential health benefit coverage requirement is subject to change depending on the future fate of the ACA and the replacement plan put forth by the Republican Party.

The top three health care insurance providers in the U.S. are:

  1. United Healthcare
  2. Anthem – Blue Cross/Blue Shield
  3. Aetna

Kaiser Permanente is another insurance provider that is offered on the health care exchange. Millions of Americans are covered by Kaiser Permanente as part of an employee benefit package.

The insurance plans offer the following:

Aetna

Aetna offers three main types of insurance plans: open-access, copay only, and high deductible. Substance treatment options and costs vary widely by specific plan coverage.

Cost also varies significantly when the treatment facility is on the “in-network” versus “out-of-network” provider list. Substance addiction treatment includes alcohol and other drugs such as opiates, prescription medications, and heroin.

Treatment options are determined by the individual’s situation and can include:

  • Detoxification
  • Inpatient/residential rehabilitation
  • Partial hospitalization
  • Intensive outpatient treatment
  • Continuing care for alumni of treatment above

With the same treatment caveats, Aetna also covers the following addictions:

  • Gambling
  • Sex
  • Internet gaming (video games)
  • Eating disorders

Consultant available 24/7 at (888) 987-6757 or for immediate medical abuse related emergency hotline at (855) 480-6989.
https://www.aetna.com

United Healthcare (part of the larger United Health Group)

Type of plan, cost, and insurance coverage depend on the specific plan details and the individual’s situation. Again, with the same treatment caveats, all of the above listed addictions are covered depending on specific plan details. One type of treatment that was not mentioned in any of the other plans is specific treatment for people with children who are exposed to addiction in the family. A different approach is utilized that extends to healing and bonding within the family.

Consultant available 24/7 at (888) 988-0437
https://www.unitedeservices.com

Anthem (Blue Cross/Blue Shield)

Available substance addiction treatment options include all the same as Aetna and, again, vary by plan specifics. Their insurance plans include specific cost sharing percentages as follows:

    • Platinum: covers 90% of costs and has the highest monthly payment and lowest deductible.
    • Gold: covers 80% of costs and has a slightly lower monthly payment and second lowest deductible.
    • Silver: covers 70% of costs and monthly payments and deductibles are on the lower side.
    • Bronze: covers 60% of costs and has the lowest monthly payments but highest deductibles.

Treatment for other addictions such as gambling, etc., is covered depending upon state of residence and the specific insurance plan.

All above plans contain a managed care component that requires ongoing approval of continuing treatment/care. It is customary now for providers to call insurance companies every few days to obtain such approval to ensure payment.

Consultant available 24/7 at (888) 986-8056
https://www.sbc.anthem.com

Kaiser Permanente

Currently, Kaiser Permanente’s health insurance coverage is available in the following states:

  • California
  • Colorado
  • Georgia
  • Hawaii
  • Wash D.C.
  • Maryland
  • Virginia
  • Oregon
  • Washington

Kaiser Permanente offers both Inpatient and Outpatient addiction treatment. Inpatient treatment may include hospitalization and can last for a period of 1-6 weeks, depending upon need. After Inpatient treatment, most insurance recipients will then move into Outpatient treatment. Outpatient is either “Standard” which is 1-2 group sessions/week or “Intensive Outpatient (IOP) therapy” which consists of 10-20 hours of counseling and group therapy over 3 days/week. IOP can also extend to 5 days/week depending on individual’s need. IOP also has 3 phases that are in 1 month, 2 month, and 3 month durations. People move from phase to phase as they complete each one. Each phase is scaled down in intensity (number of sessions). Lifetime aftercare (occasional sessions) is also available.

Insurance co-pays are determined by the individual’s health plan. The Chemical Dependency Recovery program (CDRP) does include 1 day per week that the family, friends, or significant others may attend a session, and in fact it comes strongly recommended that they do. They also recommend participation in their smoking cessation program, and emphasize the importance of a healthy diet, exercise, and other lifestyle changes that will encourage sustained recovery.

Currently, Kaiser Permanente offers treatment for all of the above listed addictions and even other addictions. Additionally, they now offer pain management without the use of prescription medication. Most locations offer acupuncture, a therapy that has been found to be very helpful in curbing cravings for alcohol.

The good news for Kaiser Permanente insurance recipients/patients is that there is no pre-certification or managed care component required by an outside insurance company (as separate from the treatment facility) since Kaiser is one in the same.

(888) 495-0246
https://account.kp.org

Obamacare

All tiers of Obamacare will offer the same essential health benefits per the Affordable Care Act (ACA). Under the Obamacare extension, states administering Medicaid (jointly funded with federal government) are required to offer substance abuse and mental health coverage. There is a fear that the GOP plan for 2020 will dispose of this requirement for Medicaid enrollees, and offer much less generous coverage, or no coverage at all.

This program currently offers four types of insurance plans: platinum, gold, silver and bronze. Substance abuse treatment options and costs vary widely by specific plan coverage. Costs and the portion of the costs which people are responsible for covering out-of-pocket do vary significantly amongst the four plans. For example a platinum plan member will by higher premiums but have a lower out-of-pocket expense while a bronze member will have a lower premium but are responsible for a higher portion of the actual cost of treatment.

For more information on current enrollment in Marketplace plans and pricing visit:
https://www.healthcare.gov/see-plans/

The following are essential health benefits that all plans must cover:

  • Behavioral health treatment, including counseling and psychotherapy
  • Inpatient treatment for behavioral health issues
  • Substance abuse treatment (also known as “substance abuse disorder”)

The specific behavioral health benefits a person can receive under this plan depend on:

  • The state in which you reside, and
  • The plan you choose (platinum, gold, silver, bronze).

A full list of plans and coverage of behavior health benefits can be found when you compare plans in the Marketplace. To see what plans are available in your state, please visit: https://www.healthcare.gov/get-coverage/

Obamacare prohibits providers from the following:

  • Denying coverage due to a preexisting condition, including substance abuse disorder or mental health conditions.
  • Putting a waiting period on coverage. Coverage for preexisting conditions must be effective the day coverage begins.
  • Setting annual or lifelong spending caps on essential health benefits.

Marketplace plans also protect coverage for substance abuse and behavioral health by requiring “parity” protections. What this means is that these essential health benefits cannot have limits applied that are any more restrictive than surgical or medical services.

The following limits are protected by parity:

  • Care management: no required preauthorization for treatment is required before receiving treatment
  • The treatment itself: limits cannot be set on the number of days or visits which are covered
  • Financial: Out-of-pocket limits, co-payments, co-insurance, and annual deductible.

See more on coverage here: https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/

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