The United States death toll from drug overdose has increased by over 200% across the last 15 years. The Patient Protection and Affordable Care Act (ACA) passed in 2012 under the Healthcare and Education Reconciliation Act, has provided a lot of financial assistance to individuals that require rehab for drug and alcohol abuse and addiction.
With this in mind, we’ve written a complete guide on how to obtain ‘Obamacare for Addiction Treatment,’ or in other words, how to use the Affordable Care Act to get you or your loved on the help they need!
Before we get into the details of the different programs available under the ACA, it is essential to understand the background of ACA – what it is, and how it works.
What is the Affordable Health Care Act?
Table of Contents
- What is the Affordable Health Care Act?
- ACA for your Healthcare
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Point Of Service Plan (POS)
- Exclusive Provider Organization Plan (EPO)
- Out of Pocket Expenses
- PPOs and Getting Your Addiction Treatment Covered
- Use Obamacare for Addiction Treatment Now!
The Affordable Healthcare Act (sometimes known as ACA, or “Obamacare”) increased the scope of healthcare by reforming existing laws regarding public healthcare and federally-funded government insurance programs. It introduced three main goals to the existing sector:
- To make health care insurance accessible and available to all citizens of the US by basing the cost on federal poverty levels, thus making it affordable for households with incomes of all levels
- To expand the Medicaid program and enable lower-income citizens- both families and individuals- to qualify for the program
- To provide reasonably priced and affordable treatment to all citizens by supporting medical delivery methods that reduce the margins between the costs of medical care, and the existing treatment plans
Private insurance companies’ costs and limits were not realistically attainable for millions of Americans, and the ACA program thus provided insurance to those who were previously uninsurable.
This also includes those suffering from addictions, as the ACA program does not consider addiction to be a pre-existing condition and offers treatment coverage that is similar to private insurance.
The ACA’s comprehensive reforms also catered to the inclusion of substance use disorders (SUD) among the ten essential elements of health benefits. This ensures that Health Insurance Exchanges or Medicaid-based insurance programs are all mandatorily required to cover treatment for substance use disorders for newly eligible adults, 2014 onwards.
This is extremely beneficial as it ensures that healthcare providers are fairly reimbursed for rehabilitation services, which improves accessibility for individuals who require help.
The Department of Health and Human Services determined the services that shall be covered after evidence-based consideration regarding the treatments that actively help individuals recover.
Therefore, addiction recovery programs are treated the same as any other medical procedure and include:
- Treatment and medication
- Clinical treatment
- Home visits
- Anti-craving medication and other detox programs
The five Marketplace plans sponsored by the ACA cover expenses based on the following categories:
- Bronze plans – 60 percent expense coverage
- Silver plans – 70 percent expense coverage
- Gold plans – 80 percent expense coverage
- Platinum plans – 90 percent expense coverage
- Catastrophic — 60 percent coverage of the total average cost
ACA for your Healthcare
The ACA reduced costs for addiction treatment, thus increasing the scope of options available and also improving accessibility for individuals who may not have been able to previously afford treatment.
- Close to 12 million Americans have enrolled in various Health Insurance Marketplace programs from February 2015 onwards.
- 87% of the enrollees on the ACA website have qualified for assistance
- 32 million Americans have received treatment for substance abuse
Essentially, the ACA has improved equality in the medical and behavioral health treatment sphere and has been crucial in providing help when required. It has significantly improved patient protections and decreased the amount of lifetime dollar limits that acted as a ceiling to public health insurance benefits.
The ACA also abolished restrictions on pre-existing conditions which had previously prevented individuals from accessing help. This means that:
- Marketplace plans cannot deny an individual coverage or increase their charges, based on pre-existing conditions such as mental health and substance abuse
- Treatment coverage for pre-existing conditions begins on the day the coverage beings
- Marketplace plans cannot put dollar limits on yearly or lifetime plans for any programs pertaining to essential health benefits including substance abuse and mental health disorders.
Furthermore, it has made healthcare and insurance companies more accountable regarding their community outreach programs, and their treatments.
Thus, the ACA has ensured that all plans must cover:
- Behavioral health treatment including psychotherapy and counseling
- Mental and behavioral in-patient services
- Treatment for substance abuse
For more general information, please visit our article on the Marketplace for the Affordable Care Act. And be sure to read on for the main insurance plans and types, as well as general recommendations on insurance plans for addiction treatment that are fully covered below.
Health Maintenance Organization (HMO)
Health Maintenance Organization (HMO) is a popular insurance plan available on the Health Insurance Marketplace, structured to provide coverage through its physician network.
It provides insurance coverage in return for a fee billed monthly or annually. However, the care provided is limited to a network of providers within the HMO contract which enables premiums to be lower than traditional insurance costs. This is because it is beneficial to the health providers as the patients are directed towards them.
As an organized public or private entity, an HMO offers basic and supplemental health services to its customers and establishes contracts with physicians, clinical facilities, and specialists, and pays them a specific fee based on their agreement to provide specific services to their subscribers.
There are also legally stipulated requirements regarding the plan’s provisions for basic healthcare in exchange for regular, fixed premiums under the ‘community rating’.
This ensures that the quality and standard of care are maintained at an affordable rate.
In-Network vs Out-Of-Network Coverage for Rehab
Individuals may also be required to live or work within the plan’s network area for coverage to be applicable.
Though most treatments must be undergone through a doctor or specialist who is part of the HMO’s network, certain services such as emergency dialysis and hospitalization may be covered under the HMO. This also applies to situations where a subscriber receives urgent care while not within the HMO’s coverage region.
In case a subscriber has received non-emergency care while out-of-network, they may be liable to pay out-of-pocket.
Deductibles for Addiction Treatment
HMO deductibles are typically low or non-existent as the organization charges a co-pay for individual visits to the clinic, or for specific tests or prescriptions.
These co-pays usually range between $5-$20 per service and help minimize expenses that are born out-of-pocket which helps make HMO plans reasonably affordable for families and employers.
Preferred Provider Organization (PPO)
A PPO medical plan involves the provision of professional services and facilities to subscribers at discounted rates. The medical providers and healthcare professionals who are part of this plan are called ‘Preferred Providers’.
PPO subscribers have the freedom to pick any service provider within their network – to receive maximum benefits. They might also receive out-of-network coverage. However, this has a higher insurance rate.
PPO essentially works by creating a contractual network of professionals and faculties through which their subscriber receives health care and services. The fees and schedules for the services provided by these ‘preferred providers’ are usually lower than the usual rate as the PPO pays these networked providers a certain fee to gain access to it.
Co-Payment, Deductible, and In-Network and Out-of-Network Coverage
A PPO subscription requires either a co-payment on a per-visit basis or a deductible before the claim is covered by the insurance. The subscriber is free to use any provider within the network and is encouraged to have a primary care physician. This is not mandatory, and they also do not require a referral for a visit with a specialist.
PPO offers out-of-network servicing at a reasonable and customary fee schedule, and if the claim exceeds this amount, you may be responsible to pay the excess fee yourself.
PPO plans usually charge higher premiums as they cost more to administer and manage, but they also provide more freedom and options as the large network has providers in most cities and states and are thus more flexible and easily accessible.
Point Of Service Plan (POS)
A POS program is a managed-care insurance program that depends on whether the customer subscribes to in-network or out-of-network service providers.
It blends the features of HMO and PPO but only holds a small share of the health insurance market as most customers subscribe to an HMO or PPO plan.
Under this plan, the subscriber is required to select a primary care provider within the network and obtain referrals for a specialist that the policy might cover. The policyholder is allowed to use out-of-network services but may have to pay a higher fee than that for services provided within the network. However, exceptions are made and the POS plan may pay more if the primary physician has made a referral to the out-of-network service.
The premiums for POS plans fall in the middle of the lower premiums of an HMO and higher premiums of a PPO.
Copayments and Deductibles
In-network copayments required of POS subscribers range between $10 to $25 per visit or appointment, and they do not require deductibles for these in-network services.
However, the out-of-network deductibles are extremely high, and patients may be required to pay for the complete cost of service until they fulfill the plan’s deductible.
POS plans are covered nationwide and are thus preferred by those who travel frequently. However, they are relatively more expensive and thus not as common as the two former plans.
Exclusive Provider Organization Plan (EPO)
Under an EPO plan, you are provided access to medical practitioners and facilities within the EPO network only. This means that you cannot get any out-of-network benefits. However, this may be exempted if you require emergency care. In general, EPO plans are among the least advantageous to acquire If seeking treatment for addiction or alcoholism beyond occasional counseling.
These packages are only feasible in situations where you do not wish to be referred to a specialist, or you want to negotiate an extremely low rate with an EPO plan, which you may not get with an HMO or PPO plan.
Most EPO plans expect you to select a primary care physician (PCP) who may provide preventative care and treat your minor or chronic illnesses. Monthly premiums for EPO coverage may be lower, but you could pay a much higher rate out-of-pocket before the insurance covers your medical expenses.
We’ve explained what these out-of-pocket and deductible expenses are below.
Out of Pocket Expenses
These are the costs that are incurred by an individual from their own funds, thus the name ‘out of pocket’.
It refers to the share of insurance costs such as deductibles, copays, and co-insurance that you shall pay for yourself, though you may be reimbursed for the same eventually.
These costs are your share of the medical expenses, and most health insurance plans have a maximum limit of out-of-pocket expenses that you may have to pay each year for covered expenses.
Essentially, the portion of the bill that is not covered by your insurance, or that you shall have to pay yourself, is referred to as an out-of-pocket expense.
A deductible is an amount you are required to spend before your insurance policy comes into play to cover some or all your remaining claims.
Deductibles are used by companies to ensure that the policyholder will share the cost associated with a claim, and also help act as a cushion against severe financial losses from occurring at one go.
Generally speaking, a higher premium will have lower deductibles and vice versa.
PPOs and Getting Your Addiction Treatment Covered
So far, we’ve done a thorough explanation of many of the basic concepts surrounding the ACA and its effectiveness for helping in addiction treatment – but what about the actual insurance providers working behind the scenes?
In a nutshell, most good PPOs will offer the following three features:
- Out-of-network coverage
- Out-of-state coverage
- Substance abuse/mental health coverage
While no PPO is perfect, we can explore a couple of providers to understand what we’re looking for:
One of the oldest and most relied-upon PPOs in the business, Aetna has been providing Americans with health insurance plans for over 150 years and continues to give solid coverage options, especially for substance abuse patients.
Out of the three needs mentioned above, Aetna offers good coverage that helps get addicts the assistance they need. While it offers a reasonably good out-of-network system, it does not offer out-of-state coverage, except for emergency cases.
Depending on the level of your plan, Aetna offers access to psychiatrists, psychologists, counselors, therapists, social workers, psychiatric nurse practitioners, and primary care doctors – all geared towards providing you with medication and therapy along with specific programs designed for, say, alcoholism.
Blue Cross Blue Shield
Another health insurance giant, Blue Cross Blue Shield provides a robust set of coverage programs for millions of policyholders and continues to expand its network with competitive pricing and good benefits.
BCBS may not offer as detailed a substance abuse program when compared to Aetna – it covers all the basics, however, and is a solid choice especially for those who move across state borders frequently.
Blue Cross Blue Shield is one of the few American insurance providers that offer out-of-state care, according to 2020 documentation. While most companies do offer out-of-state emergency care, having general treatment options available regardless of your location can be a lifesaver – making their PPO well worth considering for its complete range of coverage.
Use Obamacare for Addiction Treatment Now!
The ACA has certainly benefited individuals in desperate need of healthcare, especially those suffering from addiction disorders who are frequently mistreated and lack the resources or access to life-saving and altering healthcare.
Though medical insurance can seem complicated and intimidating, the ACA’s efforts to provide different plans to satisfy different types of customers and their unique requirements with regards to in-network and out-of-network coverage, deductibles, and cost of premiums has proven successful.
Previously, individuals suffering from addictions only received help in dire circumstances whereby their life or sanity was at stake, and treatment became absolutely necessary. However, this changed with the ACA and it became increasingly popular for addiction to be treated like any other disease or illness.
Prevention and intervention have become a focal aspect of battling the addiction epidemic that has taken over the United States and efforts to control it include:
- Medical screenings
- Educational campaigns
- Community prevention activities against drugs and alcohol
Though insurance companies do cover treatment services for addiction disorders to help, patients may incur a degree of out-of-pocket costs, and the amount due usually depends on the plan in question. Refer to our outlines and guidance above for the types of plan least likely to cause these out-of-pocket expenses.
Therefore, it is essential to be well-informed about the available plans and their policies regarding deductibles, out-of-network coverage, and out-of-pocket fees.
In terms of getting the best addiction treatment: once you have decided on a solid, PPO-based plan with good out-of-network coverage and substance abuse and mental health, reach out immediately to our expert staff and learn about the options for top-tier treatment providers available both locally and nationwide.
Please do not let lack of insurance stop you from getting into treatment, refer to this article and enroll with an effective Marketplace plan to get the help you need! Today is the day to begin living free of the shackles of drugs and alcohol and embrace the freedom of recovery, so please reach out now.
Edward lives and works in South Florida and has been a part of its recovery community for many years. With a B.A. in English Literature from the University of Massachusetts, he works to help Find Addiction Rehabs as both a writer and marketer. Edward loves to share his passion for the field through writing about addiction topics, effective treatment for addiction, and behavioral health as a whole. Alongside personal experience, Edward has deep connections to the mental health treatment industry, having worked as a medical office manager for a psychiatric consortium for many years.