Will my Health Insurance Cover Substance Abuse Treatment?

Substance abuse is a serious issue that affects many Americans. Fortunately, getting insurance to cover the costs of substance abuse treatment is becoming easier than ever.

Substance Abuse Addiction Treatment

In the past, insurance companies offered little or no coverage for substance abuse treatment. Luckily, a law that took effect in 2010 changed all that.

In the United States, the Affordable Care Act (ACA), also called Obamacare, offers ways to connect people who want to buy health insurance with companies that sell it. Insurance companies that want to be part of the ACA marketplace must cover 10 important health issues, including mental health and addictions.

In addition, all state Medicaid programs have to offer mental health care. Some of them also offer substance abuse help. Insurance companies who choose not to be part of the ACA marketplace often cover addiction treatment as well.

Why Substance Abuse Treatment is Important

First, substance abuse is an expensive problem. According to the National Institute on Drug Abuse, substance abuse costs more than $740 billion per year in crime, health care costs, and lost productivity.

Addiction care is an important benefit for lots of reasons beyond saving money. It keeps people out of emergency rooms and ambulances due to overdoses. Getting people off drugs helps them avoid going to jail. It also prevents other health problems that come from drug abuse.

Mental health and substance abuse affect each other. People with mental health problems may use drugs as a way of self-treating. People who become addicted to drugs may go on to develop mental health problems. According to the Substance Abuse and Mental Health Services Administration, 7.9 million adults have both a substance abuse problem and a mental disorder.

The impacts of drug abuse stretch across generations. Kids who are exposed to adults who do drugs are more likely to get in trouble themselves. Treating a parent's substance abuse problem is a way to help prevent drug addiction in that person's children.

Help for All Kinds of Addictions

The 2014 National Survey on Drug Use and Health found there were 20.2 million adults with a substance use disorder of some kind. That number is equal to 8.4 percent of the US population.

In most health plans, coverage for addiction treatment doesn't say which type of drug. That means, if you have insurance that covers any substance abuse, what you are addicted to will not matter. You can get care no matter what drug is causing the problem.

Where is the Care?

The National Institute on Drug Abuse says there are over 14,500 drug treatment centers in the US.

Drug abuse and addiction treatment happens in a variety of settings. Doctors' offices and clinics are outpatient care. Live-in programs like rehab qualify as inpatient care.

Just because these doctors and centers exist, though, doesn't mean your insurance will pay for them. It's important to do some research first.

Types of Substance Abuse Treatment

Types of drug abuse care that insurance might cover are:

  • Inpatient care at an approved facility
  • Outpatient care from an approved provider
  • Medical detoxification medicines and treatment
  • Individual or group counseling
  • Maintenance medications

Long-term inpatient care is what many people picture when they hear the word "rehab." People stay in these non-hospital settings 24 hours a day for 6 to 12 months.

Inpatient treatment includes regular, even daily, therapy. Learning to hold new beliefs and gain new skills is a big part of this kind of care. Being around other people with the same kind of problem helps, too.

Outpatient addiction care often costs less. It's also easier for people to do and still be able to go to work. The level of care can range from simple education about drug use to more intense daylong programs with group counseling.

Outpatient care for substance abuse also includes self-help groups like Alcoholics Anonymous. Other groups include Narcotics Anonymous and Cocaine Anonymous. These are often called "12-step" groups.

Medical detox programs can help people with addiction start to get off drugs. Trying to stop taking an addicting drug can be very hard, or even fatal. Many people relapse. Detox can help with the physical symptoms. A person will still need other care to stay sober.

Maintenance Medications

For some people, getting completely clean or sober just isn't possible. Their addiction may have been going on too long, or they may have taken too much.

Maintenance drugs can be helpful. Medications like Suboxone, buprenorphine, naltrexone, and Antabuse can help people stay away from using alcohol, opioids, or street drugs. Some of these medicines can cost a lot.

Luckily, many insurance companies are willing to pay for them. Medicare and Medicaid will only pay for maintenance drugs if they think it is vital for a person's ongoing health.

In-Network and Out-of Network

Insurance companies often have special connections with certain providers. These connections are the difference between "in-network" and "out-of-network" providers.

The difference usually has an effect on how much you will have to pay and how much coverage your plan offers. For example, if a therapist is in or out of the network might put a limit on the number of counseling sessions your insurance will pay for.

In-network providers are your best option when it comes to cost. If you aren't sure if a doctor or clinic is in-network, it's a good idea to call your insurance company.

The insurance company phone number is usually on the back of your insurance card. Ask them for the "summary plan description" and "summary of benefits and coverage" sheets for your plan. This information might be available on the internet.

You could also ask the provider if they know what services will be covered. It will save you a lot of time, money, and worry.

If your health plan won't pay for a certain service that you need, you can appeal a denied claim. That means you can ask the insurance company to take another look at their decision not to pay. They might change their decision. This is a legal right. Call your health plan and ask how to submit an appeal.

Frequently Asked Questions

Q: How does the ACA help people with addiction problems?

A: The ACA makes sure that people have access to mental health and substance abuse care. Making insurance plans offer these kinds of care is a big change from older laws. These rules are on top of the Mental Health Parity and Addiction Equity Act of 2008. That means an insurance plan has to offer the same amount of coverage for mental health as they do for medical issues.

Q: What is behavioral health?

A: The term "behavioral health" describes the services provided for either mental health issues or addiction issues. Insurance companies, Medicaid, and the Children's Health Insurance Program (CHIP) use this term to talk about treatment for mental health or substance abuse.

Q: What if the drug I am addicted to is illegal?

A: It does not matter what kind of drug problem you have. If your insurance plan covers substance abuse, it will cover it for whatever substance is involved. They cannot deny care for a drug problem because the drug isn't legal.

Q: What if my child needs substance abuse care?

A: Childhood is a time of brain growth. Drug use can cause real damage in kids and can lead to addiction.

According to the Drug Enforcement Administration, children can be protected from the risk of drug abuse in a few ways:

  • Having a tight bond with a parent or caregiver
  • High self esteem
  • Having a parent or caregiver who talks regularly with the child about drugs
  • Being active in church, school, athletic, or community activities
  • Spending time around positive role models
  • Living in a community that offers youths activities where drugs and alcohol are not tolerated
  • Attending a school with an effective alcohol and drug education program and a zero-tolerance policy for alcohol and drugs
  • Believing that using drugs may be harmful or risky

If your teen or young adult has a drug addiction, you can get help. Medicaid and the Children's Health Insurance Program (CHIP) provide free or low-cost care to eligible kids up to age 19. Covered care includes substance abuse treatment.

Q: Can you make someone get substance abuse treatment? Can the court force them to? Who will pay for it?

A: When someone you love is addicted, you want to fix it. Forcing someone to get help might seem like the only way. The court can also make someone get substance abuse treatment instead of serving jail time or paying a big fine.

In the end, though, the addicted person is in charge of their own recovery, and the court does not pay for it. You will need to find a program that is covered by your loved one's insurance policy.

If they are not insured, state-funded rehab is an option. Check the list of government offices from the Substance Abuse and Mental Health Services Administration to find a program near you.

Q: Will my insurance company pay for an Antabuse prescription?

A: Antabuse (disulfiram) is a prescription drug that makes you very sick if you drink alcohol. People who take it will have a good reason not to drink.

If you have insurance, it's very likely that your health plan will pay for Antabuse. You will still have to pay a copay. Using a mail-based pharmacy service can save you some money on copayments.

Medicare will also pay for Antabuse and a number of other substance abuse medicines.

If you have no insurance at all, the nonprofit organization NeedyMeds might be able to help you get Antabuse or other medicines for little or no cost.

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