Women's Health Insurance Guide for Addiction Treatment

In This Insurance Guide

Insurance Guide Content Overview

According to a report supported by the National Institute on Alcohol Abuse and Alcoholism, women are more likely than men to face multiple barriers to accessing substance abuse treatment and are less likely to seek treatment.

Women typically consume less alcohol, drink alcohol less frequently, and are less likely to develop alcohol-related problems than men. Similarly, women are less likely than men to use illicit drugs and to develop drug-related problems.Fortunately, covering addiction care aids states in reducing costs. A PBS report states that putting an adult in prison for a year costs around $37,000 but providing residential care for addiction costs only $14,600. That means states have a vested interest in ensuring addiction care is provided for.

There are a number of ways to cover the costs of rehab with insurance including (but not limited to): public insurance, private insurance, and group insurance.

All marketplace plans cover substance abuse services as essential health benefits. According to HealthCare.gov, that means all plans must cover substance abuse treatment.

Your specific benefits will depend on your state and the health plan you choose. You’ll see a full list of what each plan covers, including benefits, when you compare plans in the marketplace. Pre-existing behavioral substance use disorder conditions are covered, and spending limits aren’t allowed.

  • Marketplace plans can’t deny you coverage or charge you more just because you have any pre-existing condition, including substance use disorder conditions.
  • Coverage for treatment of all pre-existing substance use disorder conditions begins the day your coverage starts.
  • Marketplace plans can’t put yearly or lifetime dollar limits on coverage of any essential health benefit, including substance use disorder services.

Know Your Rights

  • You can change your doctor if you are not satisfied.
  • You can see and get a copy of your medical records. You can add your own notes to your records.
  • You have the right to keep your medical information private.
  • You can get a second medical opinion when you are given a diagnosis or treatment option.
  • Understand your health care rights.

Here in California, addiction specialists must meet the requirements set up in the California Code. This means they have a minimum of one hundred and fifty-five hours of classroom education and meet the competencies listed in Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, (AKA TAP 21). Specialists have to be trained in servicing the special populations too, including people with disabilities or co-occurring disorders. They are also educated in ethics, communicable diseases, as well as sexual harassment prevention. 

Substance abuse counselors must register with a certification board and follow their requirements to the letter and they have to be registered within six months of starting work. As of 2014, addiction specialists must take an additional nine hours of 

introductory coursework before they can formally register.

Will my health plan cover residential treatment?

Plans must cover medically necessary residential treatment for certain substance use disorder conditions and may cover residential treatment for other mental health conditions as well.  A residential treatment center provides long-term treatment and 24-hour supervision for individuals requiring ongoing and a more structured substance use disorder therapy environment. It is usually less restrictive than a psychiatric hospital.

A few questions to ask your provider include the following:

  1. How long could residential treatment last?
  2. Is residential treatment covered for my substance use disorder condition?
  3. What will I have to pay?
  4. Where is residential treatment provided?
  5. What are the names of contracted facilities?

You will need prior approval from your health plan before you or a family member receives residential care treatment. If your plan says the treatment is not medically necessary, you can file a complaint with your plan.

Do insurance plans have to cover rehabilitative benefits?

As of 2014, most individual and small group health insurance plans, including plans sold on the marketplace are required to cover substance use disorder services. Medicaid Alternative Benefit Plans also must cover substance use disorder services. These plans must have coverage of essential health benefits, which include 10 categories of benefits as defined under the health care law. One of those categories is rehabilitative and habilitative services. Additionally, these plans must comply with substance use parity requirements, as set forth in MHPAEA, meaning coverage for substance abuse services generally cannot be more restrictive than coverage for medical and surgical services.

What are MHPAEA requirements?

In general, for those in large employer plans, if substance use disorder services are offered, they are subject to the parity protections required under MHPAEA. And, as of 2014, for most small employer and individual plans, substance use disorder services must meet MHPAEA requirements. If you have questions about your insurance plan, we recommend you first look at your plan’s enrollment materials, or any other information you have on the plan, to see what the coverage levels are for all benefits. Because of the Affordable Care Act, health insurers are required to provide you with an easy-to-understand summary of your benefits, which should make it easier to see what your coverage is. More information also may be available via the Mental Health and Addiction Insurance Help consumer portal prototype and with your state Consumer Assistance Program (CAP). Additional helpful information on what you can do to better understand the parity protections you have is available in Know your Rights: Parity for Mental Health and Substance Use Disorder Benefits.

Does Medicaid cover substance use disorder services?

All state Medicaid programs provide some substance use disorder services to beneficiaries, and Children’s Health Insurance Program (CHIP) beneficiaries receive a full-service array. These services often include counseling, therapy, medication management, social work services, peer support, and substance use disorder treatment. While states determine which of these services to cover for adults, Medicaid and CHIP requires that children enrolled in Medicaid receive a wide range of medically necessary services. In addition, coverage for the new Medicaid adult expansion populations is required to include essential health benefits, including substance use disorder benefits, and must meet substance abuse parity requirements under MHPAEA in the same manner as health plans.

Does Medicare cover substance use disorder services?

Yes, Medicare covers a wide range of substance use disorder services.

Medicare Part A (Hospital Insurance) covers inpatient substance use disorder care services you get in a hospital. Part A covers your room, meals, nursing care, and other related services and supplies.

Medicare Part B (Medical Insurance) helps cover substance use disorder services that you would generally get outside of a hospital, including visits with a psychiatrist or other doctor, visits with a clinical psychologist or clinical social worker, and lab tests ordered by your doctor.

Medicare Part D (Prescription Drug ) helps cover drugs you may need to treat a substance use disorder condition. Each Part D plan has its own list of covered drugs, known as the formulary. Learn more about which plans cover which drugs.

If you get your Medicare benefits through a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, check your plan’s membership materials or call the plan for details about how to get your substance use disorder benefits.

Marketplace plans must provide certain “parity” protections between substance abuse benefits on the one hand, and medical and surgical benefits on the other. This generally means limits applied to substance abuse services can’t be more restrictive than limits applied to medical and surgical services. The limits covered by parity protections include:

  • Inpatient care in an approved facility
  • Outpatient care with an approved provider
  • Medical detox, including medications
  • Co-occurring mental health conditions
  • Follow-up counseling
  • Maintenance addiction medication

HealthCare.gov reports that plans participating in the insurance marketplace must provide care in 10 essential health categories,Health Insurance for Womens Addiction Treatment one of those being addiction care. The amount of coverage or insurance acceptance is based on each client’s specific insurance policy that means out-of-pocket expenses will vary. 

The majority of insurance policies do not split drugs into “covered” and “non-covered” sections – that way, if addiction treatments are a covered benefit then regardless of what the addiction’s root is, care will be provided. This model is also used by health insurance companies to attend to other medical conditions.

Maintenance Plans

If you’re in a maintenance program, then you will most likely have been through rehab but need medication to correct chemical imbalances that have been caused by abuse. Medications include Suboxone, buprenorphine, and Antabuse are generally prescribed in these situations and they are generally covered by insurance companies.

California Insurance Companies and Coverage

Aetna offers open-access, copay-only, and high-deductible health insurance plans. Despite the coverage options and costs varying dramatically, all of them could help you to pay for drug rehab. Use Aetna’s online tool to view coverage details, and contact customer service support online to ensure that the program you would like to use is covered by the plan you are enrolled in. Anthem, Inc., an organization within the Blue Cross and Blue Shield Association, serves over 70 million people. Over 38 million people are covered under Anthem health plans, which translates to about one in nine Americans. Because of its affiliation with Blue Cross and Blue Shield, Anthem insurance shares the same widespread national reach as BCBSA. Anthem has processed over 670 million claims and boasts over 210 billion in benefits paid. They own Anthem Blue Cross and Blue Shield, Anthem Blue Cross, Empire BlueCross BlueShield, Blue Cross and Blue Shield of Georgia, and Anthem Life Insurance. They are affiliated with 13 other companies.The Blue Cross and Blue Shield Association owns 36 health insurance companies nationwide, which make up the Blue System. Collectively, the companies cover over 105 million Americans and operate in all 50 states. Commonly referred to as The Blues, Blue Cross and Blue Shield have over half of all federal employees enrolled in their network. With 9.6 million members in 2014, approximately 17,791 doctors and 659 medical offices, hospitals, and facilities, Kaiser Permanente is a top-tier, not-for-profit health plan service and healthcare provider. Kaiser Permanente is one of the primary healthcare providers in the United States offering coverage in eight different states (Washington, Oregon, Colorado, California, Hawaii, Georgia, Virginia, and Maryland), as well as the District of Columbia.State Farm provides primary medical insurance plans for individuals in the following states: Wisconsin, New York, California, Connecticut, Georgia, Colorado, Illinois, Missouri, Mississippi, Maine, Montana, Indiana, Ohio, Nevada, Oklahoma, Texas, South Carolina, and Virginia. UnitedHealth Group is a distinctively diversified health and well-being company headquartered in the United States, and a leader worldwide in helping people live healthier lives and helping make the health system work better for everyone.

We Can Help

Knowing your insurance options helps you fight your addiction – and hopefully provides relief knowing you can afford the help you need. If you would like more information on the coverage of your existing insurance benefits for substance abuse treatment, please contact us today to receive a free, confidential assessment over the phone. Our team will collect your benefits information and verify your eligibility for treatment over the phone. Or feel free to verify your insurance online by clicking below.