Understand the Affordable Care Act
Not very long ago, it was hard to know if your health insurance had any coverage for addiction treatment at all. Sometimes the payment was very limited or had a separate, extremely high deductible. The Affordable Care Act (ACA) changed that. Passed in 2010, the ACA required all long-term health insurance plans to abide by specific rules. One of the most important, when it comes to addiction treatment, was the creation of mandatory essential health benefits. Essential health benefits must be covered by all long-term plans. Behavioral and mental health services are included with this group, which means all plans have to have some coverage for addiction treatment.
Specifically, all long-term plans must cover:
- Psychotherapy, counseling, and other behavioral health treatment for mental illness
- Inpatient services for mental and behavioral health
- Substance abuse disorder treatment
Of course, different plans will have varying coverage. Some plans may have higher deductibles or copayments than others. Or, you might have to choose an in-network provider to get health insurance payment. Pre-existing conditions cannot be excluded, and insurance plans are not allowed to have annual or lifetime spending limits on any essential health benefit. The essential health benefits, including addiction treatment, have to be covered at the same percentage as other medical procedures.
Thanks to the Affordable Care Act, you can approach your insurance company about substance abuse treatment with confidence.
Different Types of Health Insurance Plans There are a variety of health insurance plans available, and it’s important to understand which one you have. The types of insurance coverages will vary depending on your plan. It can be challenging to sort through the acronyms, so let’s look at each one briefly.
A Preferred Provider Organization (PPO)
The most flexible — but also the most expensive — type of health insurance is a PPO. You’ll generally pay more per month for this type of coverage compared to other plans. However, you’ll have maximum choice when it comes to providers and treatment.
With a PPO, you generally do not have to have a primary care provider (PCP) designated, and you don’t need referrals to see a specialist. There is a provider network that the insurance company prefers, but you aren’t required to use them.
If you do use the in-network providers, your copayments and deductibles will be lower. Outside the network, they will be higher — sometimes extremely high.
You might also need preapproval from the insurance company before you get your treatment. Without preapproval, the insurer might deny coverage. Make sure you keep that in mind if you plan to use a PPO for addiction treatment.
Health Maintenance Organizations (HMOs)
Another common type of insurance is an HMO. You will need to designate a primary care provider (PCP) and see them first for your medical needs. Your PCP will give you referrals to other providers and specialists, so make sure it’s someone you trust.
Your monthly premium with an HMO will be lower, but you’ll have fewer choices about your providers. The insurer will only provide coverage for in-network care. If you’re outside the network, there is no help from your health insurance unless it’s an emergency situation.
As with almost all health insurance plans at a majority of insurance providers, you’ll need preapproval for some services. Make sure you check your insurance before signing up with a detox or treatment facility.
Exclusive Provider Organizations (EPOs)
An exclusive provider organization combines some of the features of a PPO and an HMO. For instance, you don’t have to have a PCP or get referrals for specialists. However, you have to stay within the insurer’s network for care.
With larger networks like Blue Cross Blue Shield (BCBS) or Aetna, that’s not likely to be a big concern. However, you’ll still want to do your research. If you have a smaller insurer, you’ll have to be especially careful in where you seek treatment for substance abuse disorder.
You may need preapproval with an EPO plan, so be sure to check with your insurer before committing to a medical procedure or process.
Point of Service (POS) Plan
A point of service plan also combines some elements from an HMO and PPO. In this case, you’ll need a PCP and referrals for specialty care. However, you may be able to get coverage outside your network if your PCP refers you.
Generally, you’ll need to stay in your network, and you may need preapproval for specific procedures. Your PCP may take care of preapproval for you, but don’t assume — always ask!
Use Your Insurance For Addiction Treatment
Now that you know how to use your insurance for addiction treatment, it probably seems a lot less overwhelming to look for help. The ACA means that detox and addiction recovery is covered by all long-term health insurance plans.
The next step is to know what treatment program is right for you. If you’re looking for help in the Los Angeles area, let us be there for you. We have addiction professionals with decades of combined experience and we work hard to use the most effective and evidence-based plans.
We have a variety of treatment options and our program isn’t so big that you’ll be lost in the process. You’ll have an individualized treatment plan designed to give you the maximum chance at recovery.
If you’re ready to start a new life of sobriety and freedom, contact us today!