Insurance Coverage of Substance Abuse – Am I Covered?

There was a time where insurance coverage for substance abuse and mental health was quite limited. The Affordable Care Act changed this for the better. Today, mental health and substance services must now be included in all qualified health plans as essential health benefits.

This means that any ACA-qualified plan will include benefits for this care. All plans must also provide the same level of care for mental health issues that they do for medical health issues.

More importantly, this coverage begins the same day that your coverage starts. There are no waiting periods for pre-existing mental and behavioral health conditions. There are also no annual or lifetime limits on the amount of care that you may receive.

All ACA-qualified benefit plans must include:

–Behavioral health treatment, such as counseling

–Mental and behavioral health inpatient services

–Substance use disorder treatment

Specific behavioral benefits may vary by state. You’ll be able to see these benefits when comparing plans in the Marketplace.

The Mental Health Parity and Addiction Equality Act also provided parity protection for mental health services. This means that plans cannot limit mental health or substance abuse services any more than they can limit any standard medical services. The care offered for substance abuse must be on par with care offered for medical conditions.

It’s important to note that not all centers participate in insurance networks, so it’s important to speak with your chosen care facility about what coverage they do accept and what your payment options are.

The ACA provides an open enrollment period every fall where you can switch your insurance provider. If a certain insurance provider has a network relationship with a center that you wish to treat at, you will have the option to change your insurance coverage for the following year during the fall open enrollment period.

Medicare Coverage of Substance Abuse

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For people over 65, Medicare offers fairly broad coverage for substance abuse treatment.

Medicare Part A will help to pay for your care if you are hospitalized to receive substance abuse treatment at a treatment center that accepts Medicare. (Yellowstone does not participate in or accept payments from Medicare).

Should you receive that care in a psychiatric hospital, Medicare provides a maximum of 190 days of care. This lifetime limit is for inpatient care only. Outpatient mental health care may cover beyond that on an individual or group basis.

Medicare Part B Benefits

Medicare Part B provides outpatient substance abuse care. It pays 80% of the allowed amount for mental health services, which includes treatment for alcoholism and drug abuse.

Part B now provides 100% coverage of screening and counseling for individuals who are showing signs of alcohol misuse.

Covered services also include counseling, patient education, follow-up visits, and most prescriptions administered in a clinical setting. Beneficiaries may also choose to purchase a Part D drug plan for retail prescription medication.

Medicare Part B also provides coverage for Structured Assessment and Brief Intervention screening and intervention process. This process helps to identify people who may be at risk for substance abuse.

While Part B only covers 80% of approved services, Medicare supplemental coverage can be used to help pay for the other 20%. Beneficiaries can choose from traditional Medigap plans or the newer Part C Medicare Advantage plans. Both types of coverage help to fill in the gaps in Medicare.

Medicare Part D Benefits

Lastly, Medicare Part D is a voluntary prescription drug program that provides access to retail prescription medications. This includes medications prescribed to treat alcohol and drug addiction. All Part D plans must also include coverage for drugs for the treatment of opioid dependence when medically necessary.

It should be noted that Methadone, when prescribed for opioid dependence, is not covered by Part D because it cannot be dispensed at a retail pharmacy. Part D plans, however, may cover methadone when prescribed for pain.

Knowing your insurance options when seeking treatment can help you plan ahead for your care. Speak with your insurance agent if you are unsure what your policy covers so that there are no surprises.

Danielle Kunkle Roberts is the co-founder of Boomer Benefits, a health insurance agency in Texas.