In the U.S., health insurance companies must cover addiction treatment to some extent. The level of coverage varies according to the insurance company and an individual’s chosen plan.
Addiction is a chronic illness, meaning it requires ongoing treatment after symptoms first manifest. This disorder is a behavioral condition, and it is often associated with mental illnesses like depression and anxiety.
Addiction involves compulsive, uncontrollable behaviors to stimulate the reward system in the brain. Most often, these behaviors are associated with taking addictive drugs or drinking alcohol, but they can sometimes manifest as behaviors such as shopping or gambling.
Treating addiction requires medical supervision for detox, to end the body’s dependence on substances, and rehabilitation, which provides therapy to manage compulsive behaviors and reduce the risk of relapse. This treatment must be based on scientific and medical research, and it must be available to anyone who needs it.
Unfortunately, health insurance in the United States has not always covered addiction treatment, but with better federal laws and an improved scientific understanding of addiction as a chronic illness, expanded medical treatment is now being covered by health care.
The Affordable Care Act (ACA) went into full effect in 2014, allowing more people in the United States to purchase insurance coverage at a rate they could afford.
Part of the ACA expanded coverage requires that health insurance companies must cover mental and behavioral health treatments, which are now considered essential benefits. This includes addiction treatment. Per the ACA, mental and behavioral health services must be covered similarly to other medical services such as surgery.
However, health insurance does not have to cover every form of addiction treatment, so some cover only part of the cost, or they cover certain approaches to treatment. While the ACA has allowed expanded access to mental and behavioral health services, which is a great benefit to millions of adults across the country, it may not cover the kind of addiction treatment required.
The National Institute on Drug Abuse (NIDA) Principles of Effective Treatment states that detox and rehabilitation programs must have unique options to accommodate individual needs. For example, some people may need inpatient detox and long-term outpatient rehabilitation; however, their health insurance may not cover inpatient options.
Mental health and substance use disorder coverage parity laws have gone into effect in some states. At the federal level, access to these services is generally protected under the ACA.
The ACA states that all health insurance plans must cover:
However, there is flexibility within the ACA for states to manage treatment coverage as they see fit.
Each specific health insurance company can determine how to best approach coverage to each of these services. This means that each company will offer a list of in-network service providers, such as therapists, pharmacists, and support groups. It may take some effort and cost extra money for an individual to find the best combination of addiction treatment services for their specific needs.
For people who have struggled with addiction to a substance in the past and relapsed after some time being sober, health insurance coverage cannot deny detox and rehabilitation services because they have gone through a treatment program already. If you relapse back into substance abuse, returning to treatment will be supported by your health insurance.
Large employer plans and small individual plans alike are subject to health parity laws and must meet parity requirements. This does not provide a lot of specific options, depending on the insurance plan.
A survey conducted by the American Psychological Association (APA) found that 90 percent of Americans were unfamiliar with mental and behavioral health parity laws in 2014.
If you do not know whether your insurance covers detox and rehabilitation options, start by looking at the enrollment materials and insurance coverage details in the booklet sent to you by your insurance company. You can also ask a human resources representative or administrator at work about your employer-covered insurance, or you can call the insurance company directly and ask about these benefits.
Your health insurance company should make their contact information clearly available in their booklet and on their website. A phone call should lead you to a customer service representative or a phone tree. When put through to a phone tree, click through the options that sound correct; if you are unsure, press zero (0). This usually will get you through to a customer service representative.
Although the ACA and mental/behavioral health parity laws have expanded coverage for mental, behavioral, and substance abuse treatment, insurance companies vary in what they are willing to cover.
Many basic insurance plans only cover one month (28 to 30 days) of outpatient detox and rehabilitation, which is not enough. NIDA is clear that 90 days, or three months, is the minimum amount of time one should spend in rehabilitation for behavioral change to fully sink in.
However, getting some treatment covered can help you get started on the path to sobriety and recovery. You may be able to pay the rest of the 90 days out of pocket, raise money from friends and family, get help through employee assistance plans (EAPs), or find free support options like peer groups.
If you do not have insurance coverage or are having problems getting help from your insurance coverage, contact your state’s Consumer Assistance Program (CAP). A federal grant assist states across the U.S. to develop or expand CAPs to help residents get the most out of their health insurance.
Unfortunately, not every state has a CAP. If your state does, you should be able to call, email, direct mail, or even walk into an office and get help finding a program that is covered under your insurance.
Many states have online marketplaces for health insurance purchases, and these are open once a year. If your state does not have a health insurance marketplace, and you do not have insurance through your employer, the federal marketplace may be able to help you, or you may be eligible for Medicaid or Medicare. Both of these federal programs have some access to substance abuse treatment. Combining them with a private health insurance option may provide you with the best access to treatment options.
(January 2018). Drug Addiction Treatment in the United States. National Institute on Drug Abuse (NIDA) from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/drug-addiction-treatment-in-united-states
Mental Health & Substance Abuse Coverage. Healthcare.gov from https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
(January 2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). National Institute on Drug Abuse (NIDA) from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
(March 19, 2018). Health Insurance and Mental Health Services. MentalHealth.gov from https://www.mentalhealth.gov/get-help/health-insurance
Does Your Insurance Cover Mental Health Services? American Psychological Association (APA) from https://www.apa.org/helpcenter/parity-guide
Consumer Assistance Program. Centers for Medicare & Medicaid Services (CMS) from https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/