Does Obamacare Cover Rehab?

As vital as rehab is to the recovery of those struggling with addiction, it unfortunately faces the same stigma as everything surrounding substance abuse and mental health.

It can be difficult to seek help for paying for addiction treatment services, or even to find the right places to ask questions like “Does Obamacare cover rehab?”

Keep reading to get the answers to questions about using Obamacare for rehab, and the ways that Icarus Behavioral Health can help you understand your coverage for rehab.

All You Need to Know About Using Obamacare for Rehab

Seeking addiction treatment is already a difficult hurdle in and of itself, but the steep costs often frighten people from taking the leap as well. Many find that their health insurance is insufficient or outright excludes these costs and believe that they don’t have the capacity to pay.

If this sounds familiar to you, then you ought to be aware that the ACA Marketplace, also known as Obamacare, offers policies that can allow you to obtain various treatment services — substance abuse treatment, addiction treatment, behavioral health treatment, and more — at a fraction of the cost.

In some cases, you might not even need to spring for any out-of-pocket costs. You read that right: up to 100% of costs of rehab can be covered by the right insurance policies.

What Is Obamacare?

In the early 2010s, new healthcare reforms were instituted in the U.S. Under the Patient Protection and Affordable Care Act (ACA), known informally as “Obamacare,” and previously uninsured Americans saw access to more accessible and affordable health insurance coverage.

Studies estimated that at the time of its implementation, the Affordable Care Act allowed around 5.5 million people with addiction disorders or mental health issues to qualify for insurance coverage when they previously did not.

Where Can I Find Health Insurance Covered by the Affordable Care Act?

There are many health insurance marketplaces online, but if you’re looking specifically for ones under the Affordable Care Act, head over to the official website — HealthCare.gov. The Health Insurance Marketplace® is an official government site, where you can:

• Find answers to your questions about health insurance.
• Compare plans between health insurance companies.
• Determine if you’re eligible for healthcare programs like Medicaid or the Children’s Health Insurance Program (CHIP).
• Determine if you’re eligible for tax credits for private health insurance.
• Enroll in a health insurance plan that meets your treatment needs.

State-Specific Healthcare Marketplaces

While HealthCare.gov is the main platform for the ACA Marketplace, many states operate their own Health Insurance Marketplace platforms. This allows them to follow state-specific Medicare and Medicaid coverage rules.

Here is the directory for states that have their own Marketplace platforms. If your state is on the list, you’ll have to look for insurance plans on the state’s website.

When looking for a program, note that PPO plans, while they may have a high monthly premium, can more than make up for this with expanded coverage and low (or non-existent) out of pocket expenses.

Why Drug Rehab Was Previously Not Covered by Health Insurance Companies

Before the Affordable Care Act, many insurance companies used pre-existing conditions as reasons to bar applicants from receiving coverage. This means that they only wanted to cover future medical and surgical services if they weren’t caused by a condition that the individual didn’t have before enrolling in a plan.

Previously, those that suffered from AIDS/HIV, diabetes, pregnancy, congestive heart failure, severe obesity, severe mental health disorders, and other conditions were considered “uninsurable.” Substance abuse disorder was among these conditions.

Many of those who needed addiction treatment faced strict limits on what would be covered by their plans. However, when the ACA was enacted, insurers became forbidden from turning applicants down, charging them higher premiums, or changing coverage to exclude a pre-existing condition.

Some Exceptions to Providing Coverage for Pre-Existing Conditions

While most health insurance providers are not allowed to turn you down for a pre-existing condition, some grandfathered health plans don’t offer Affordable Care Act (ACA) protections. Grandfathered health plans are individual plans purchased on or before March 23, 2010, and have virtually stayed the same since.

As they existed before the Affordable Care Act, they are under no obligation to provide the same benefits and consumer protections outlined in the ACA (i.e. they’re well within their rights to exclude conditions that existed previously from coverage).

If you’re on a grandfathered plan and need the substance abuse coverage offered by the ACA, you can switch to a plan from the Health Insurance Marketplace® during the annual Open Enrollment Period, which begins on November 1. Alternatively, you may qualify for a Special Enrollment Period (due to a life change or estimated household income) to apply during any time of the year.

Rehab Coverage Under the Affordable Care Act

The Affordable Care Act considers rehab part of the 10 essential health benefits all plans on the Health Insurance Marketplace® must cover. Among these 10 benefits, rehab falls under “Mental health and substance use disorder services, including behavioral health treatment, counseling, and psychotherapy.”

This means that the health insurance coverage on all Marketplace plans should cover addiction treatment and rehab, providing at least minimum essential coverage according to ACA guidelines.

Types of Addiction Treatment and Mental Health Services Covered

While the specific benefits vary from state to state and plan to plan, at a minimum all ACA plans are required to cover:

• Treatment for substance use disorders
• Mental and behavioral health inpatient services at treatment centers
• Behavioral health services (e.g. psychotherapy and counseling)

On the Health Insurance Marketplace®, you can find a full list of insurance coverage under specific plans by browsing the Marketplace and using the comparison tools. As each plan is unique, it’s always important to understand their coverage availability and rates inside and out.

Ensure that the plan you’re signing up for is the best option when it comes to the addiction treatment you need, including services and medications.

What are the Protections Offered by the Affordable Care Act

Thanks to the Affordable Care Act, Marketplace plans offer you these protections for mental health and substance abuse services:

• You can’t be denied coverage or charged more for pre-existing conditions.
• Coverage for treatment, including conditions that existed previously, begins the same day your coverage starts.
• You can’t be subject to yearly or lifetime dollar limits on insurance coverage of all essential health benefits.
• There must be a certain level of fairness or “parity” between substance abuse and mental health benefits and medical and surgical benefits. This means that the limits faced by the former can’t be more restrictive than those faced by the latter. Parity protection includes:
  • Treatment — Similar limits to the number of visits or days covered (e.g. If you can get a 10-day hospital stay covered, you should also be able to get a 10-day visit at rehab centers covered.)
  • Financial — Similar limits on copayments, deductibles, coinsurance, and out-of-pocket costs (e.g. If your medical coverage has a $1,500 deductible, your behavioral treatment should also be $1,500.)
  • Care Management — Similar protocol for getting authorization of treatment before getting care (e.g. If you don’t need a doctor’s note to get surgery. You shouldn’t need one to enroll in a treatment center.)

How Most ACA Plans Deal with Costs

While this depends heavily on the plan you choose, most health insurance plans cover addiction treatment programs as part of a cost-sharing plan. This means you may still need to pay some of the costs of treatment, be it outpatient rehab treatment or stays at inpatient rehab centers.

While other health services are covered at 100%, it’s still good to be grateful for ACA programs. If you’re not in a good place to deal with sudden out-of-pocket costs, it’s a good idea to consult with our Admissions team at Icarus Behavioral Health and clarify what exactly your out-of-pocket costs will be. This will prevent you from getting blindsided later on and get a better grasp of your level of coverage.

How Rehab Costs are Calculated in Obamacare Plans

The Marketplace splits plans into four main categories. Generally, the amount you’ll need to pay for the costs of addiction treatment will vary based on the plan:

• Bronze — The insurer pays 60%, and you pay 40%.
• Silver — The insurer pays 70%, and you pay 30%.
• Gold — The insurer pays 80%, and you pay 20%.
• Platinum — The insurer pays 90%, and you pay 10%.

At Bronze, you’ll see low monthly premiums and high deductibles. This is intended for people that can cover most routine care themselves but want to protect themselves from the worst-case medical scenarios.

On the opposite end, Platinum plans offer high monthly premiums and low deductibles, which is better for people who need frequent care.

Factors That Can Affect Your Coverage

Because your situation can vary greatly from someone else’s, it’s hard to make accurate predictions for what your coverage will entail. There are two main factors that can affect your coverage when seeking addiction treatment.

Type of Insurance Plan (HMO vs. PPO)

A Health Maintenance Organization plan, known as an HMO plan, will restrict your coverage to a specific group of physicians or health care providers (called a network). On the other hand, a Preferred Provider Organization plan, known as a PPO plan, will allow you to seek treatment from any physician or treatment provider you wish, whether inside or outside the network.

Generally, HMO plans will cost you less, but PPO plans offer more flexibility. For example, the nearest treatment center may not be covered under an HMO plan. In addition, you’ll typically be required to get a referral from your primary care physician (PCP) before you can receive treatment for substance abuse disorders under an HMO plan.

Type of Addiction

Not all types of addiction may be covered by your health insurance. Of course, most of the known addictive substances will be covered (such as alcohol, opioids, and many recreational drugs).

However, our understanding of addiction isn’t set in stone and new knowledge is continually being uncovered by the medical community. Other behavioral addictions (like gambling, video games, shopping, sex, thrill-seeking, etc.) that are less understood may not be covered. It’s good to check with your PCP, your treatment provider, and your insurance provider to determine what falls under your coverage.

Limitations You May Encounter

While the Affordable Care Act ensures that you have access to affordable and accessible insurance that you can use to pay for rehab, it’s not a miracle worker. You’ll still have to do the legwork when it comes to finding the right plan for your needs.

While there aren’t set guidelines on how treatment programs should proceed, some insurance plans may require you to try outpatient options before trying inpatient care.

In addition, some plans can also restrict where you’re allowed to seek treatment. The plan that may be the best for your budget might not be the best for your location, requiring you to travel to far away treatment centers or face long waits for appointments at a covered facility that handles a lot of clients.

How Can I Determine How Much My Plan Will Cover for Rehab?

The only way you can truly determine how much a plan will cover is by communicating with your insurance company alongside the team at Icarus Behavioral Health. You can check their websites for information regarding rehab coverage, but it’s usually better to use a direct line of contact (such as phone or email) so they can advise you regarding your situation.

If you have your heart set on attending Icarus (and we certainly understand why!) contact their Admissions team to ask what health insurance plans they accept and ask about verifying the specifics of your coverage.

Verify Your Insurance Plan with Us Today

Navigating insurance policies can be incredibly intimidating, especially when your mental, physical, and financial well-being is on the line.

Don’t hesitate to call our team at Icarus Behavioral Health if you have any concerns about using Obamacare for rehab — we can help you understand your options and seek the right health insurance plans and treatment programs to begin your journey to recovery.

Whether you’ve just found an Obamacare plan and are looking for treatment, or are looking for a rehab that accepts most major policies and provides top-level care, reach out to Icarus today and start your recovery!