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Health Insurance

Today, substance abuse treatment is an essential health benefit. How much you pay for rehab generally depends on what type of health insurance you have.

Paying for Rehab With Health Insurance

Depending on your healthcare provider, paying for rehab can range from easy and uncomplicated to complex and pricey. Whether individuals are “fully insured” (pay premiums to an insurance company) or “self-insured” (employers pay healthcare costs through an insurance company), out-of-pocket costs for addiction treatment will vary as well. To pay for rehab with health insurance, most plans include payments through some form of premium, deductible, copay, or coinsurance.

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Types of Health Insurance Providers

Health insurance providers are essentially companies that collect payments (i.e. premiums) at regular intervals and also cover certain amounts of healthcare costs. The three main types of health insurance providers are government-funded, private, and group health insurance.

Government programs that provide health insurance include Medicaid, Medicare, and CHIP (Children’s Health Insurance Program). Usually, government-funded, or publicly-funded, insurance is available to low-income individuals, the elderly, or those with disabilities. This type of insurance requires an application process and proof of need.

Private, or commercial, health insurance is available through companies like Aetna, Cigna, Humana, and United Healthcare among many others. Sometimes, private health insurance is more expensive than plans provided through government programs, but they also tend to provide more healthcare options. The types of therapy (i.e. clinical, psychotherapy, massage) and amenities (from residential stays to horseback riding) covered by private health insurers differ from company to company and plan to plan. Some programs offer payments for just one type of care, and they usually limit the amount of time that someone can access that care. This includes inpatient treatment, outpatient treatment, IOP, inpatient/outpatient detox, and et cetera. Thus, it’s important to always check your benefits with your provider before booking any treatments.

Group health insurance is a type of commercial health insurance, usually provided to employees by their employers or to members of an association. 56% of non-elderly people get their healthcare through group health insurance provided by employers.

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Affordable Care Act and the Health Insurance Marketplace

Prior to 2008, health insurance providers were not required to cover mental health or substance abuse treatment. This left millions of Americans without the requisite coverage to receive drug or alcohol treatment. Starting with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 and continuing through 2010 with the Affordable Care Act (ACA), government-funded, private, and group health insurers are required to give the same level of treatment benefits for disorders like drug addiction or alcoholism as they do for conditions like Diabetes or Leukemia.

For those not enrolled in government-funded insurance or a workplace healthcare plan, insurance can also be purchased in the Marketplace (a collection of insurance plan options with tax credits available). The Marketplace was established as part of the ACA and Health Insurance Reform. The Marketplace is where individuals, families, and businesses can shop for affordable health insurance coverage to meet their requirements for the ACA. Individuals, families, and small employers can compare, choose, and buy affordable health plans. Also known as the Exchange, the Marketplace provides health plan shopping and enrollment services through websites, call centers, and in-person help. The average individual health insurance premium in 2017 cost $393 (without any tax credit); the average family premium was $1,021. Plans offered in the Marketplace cover services such as:

Health Insurance Plans

Insurance plans offered through the Marketplace, and from private insurance brokers, are categorized into tiers of coverage based on types of metal (bronze, silver, gold, platinum). Accordingly, bronze plans offer the least amount of coverage, while platinum plans provide the most. To compare, bronze plans cover 60% of healthcare costs and platinum plans cover 90%; the remaining balance is paid by the insured individual.

The table below illustrates the four most common types of health insurance plans.

Type Provider Network Deductible Paperwork Other Costs
Health maintenance organization (HMO) To see a provider, patients need doctor referral. Out-of-network visits are not covered. This is the least open plan in choosing healthcare providers. With the exception of preventative care, a deductible may be required before coverage kicks in. HMO requires no claims forms to be filled out in order to receive care or be reimbursed for it. Patient pays 100% of bill from out-of-network healthcare visits.
Preferred provider organization (PPO) Can visit providers and out-of-network doctors but may pay higher price vs. in-network. Some PPO plans have deductibles which are often higher for out-of-network visits. No paperwork for providers in-network. Out-of-network visits require filing a claim to be reimbursed. For higher-priced, out-of-network doctors, patients pay the difference after insurer pays its share.
Exclusive provider organization (EPO) More choices available than an HMO, but not completely open. However, no coverage for out-of-network visits (excepting emergency). May have to pay deductible before benefits kick in. Because EPOs don’t reimburse for out-of-network visits, there isn’t much paperwork required. Pay 100% of bill from out-of-network healthcare visits.
Point-of-service (POS) POS is a mixture of HMO and PPO plans. More options in choosing doctors/hospitals than HMO. Out-of-network visits allowed but reimbursed at a lower percentage. May have a deductible that could be higher for out-of-network care. Paperwork is required for out-of-network visits; patients file claims to be reimbursed. Some of the balance for out-of-network visits will be paid by the patient.

Insurance companies also offer a fifth type of insurance that can be comprised of the network and benefits structure of any of the four health insurance types above. A high-deductible health plan (HDHP) is available through some insurers for low monthly premiums (usually in the bronze tier) with higher deductibles. These plans come with a health savings account (HSA) – a tax-free account used for medical expenses. The provider network depends on whether the HDHP is an HMO, PPO, EPO, or POS plan. Apart from preventative care, the patient covers all expenses until the deductible is reached. Thus, it’s important to save receipts to make withdrawals from an HSA until insurance benefits start.

There are many different specialty forms of insurance available as well that are designed to help patients with specific needs. For example, there are copay assistance programs that help those who struggle with high copays associated with certain prescription medications get the treatment they need. Additionally, many religious and charitable organizations offer a variety of forms of insurance and treatment assistance.

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Finding Rehab With Your Insurance

If you are currently enrolled in insurance and are looking for an addiction treatment center, you will be able to contact your provider for available substance abuse treatment options and facilities, including drug and alcohol detox, medication-assisted treatment, and inpatient/outpatient therapy. To speak with someone about your options when choosing a rehab, talk to a treatment provider today.

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