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Are There Any Types of Drug Addiction That Insurance Doesn’t Cover?

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Are There Any Types of Drug Addiction That Insurance Doesn’t Cover?

In previous years many health insurance carriers did not include substance abuse treatment as a part of their benefits package. These companies did not provide financial reimbursement or payments for anyone who wanted to get help for their drug addiction. They would be required to pay for it personally or find government-assisted treatment. However, two recent laws have changed requirements about what health insurance companies must cover as a part of their policies.

The Mental Health Parity and Addiction Equality Act

The Mental Health Parity and Addiction Equality Act (also known as the Parity Law) signed into law in 2008 requires insurance carriers to treat mental health problems equally to physical health problems. According to the American Psychological Association, if an insurance company provides benefits for mental health and substance use disorders (MH/SUD), then those benefits must be equal to medical and surgical benefits. Elements of the Parity Law include the following:

  • Deductible amounts
  • Co-payments
  • Number of visits per year for outpatient treatment
  • Days of coverage per year for inpatient treatment
  • Out-of-network benefits

The law does not require insurance companies to include benefits for MH/SUD, but if included, those benefits must be on par with physical health benefits. The law applies to large group health plans but not small group health plans (50 employees or less). According to the American Psychological Association, a vast majority of insurance plans already provide mental health and substance use benefits, so chances are your current insurance offers some level of coverage.

Are There Any Types of Drug Addiction That Insurance Doesn’t Cover?

The Affordable Care Act

The Affordable Care Act (ACA) made sweeping changes in the health care industry. One of the new changes in the way insurance companies treats mental health disorders. Under this provision insurance company must provide treatment for mental health and substance use disorder (MH/SUD) under its umbrella of care. According to The Partnership for a Drug-Free America, SUD is now considered an essential service, which means insurance companies must treat the full spectrum of substance abuse including the early stages. Together with the Parity Law, the ACA makes it possible for about 32 million Americans to gain access to substance abuse treatment, and it will expand substance abuse benefits for an additional 31 million people according to the Huffington Post.

Each individual state is responsible for ensuring that the insurance companies operating in that state comply with the Affordable Care Act (ACA) according to the Centers for Medicare and Medicaid Services (CMS) If states cannot by state law enforcement the ACA, then the CMS will enforce compliance in that state. Current states that do not comply with the ACA include the following:

  • Alabama
  • Missouri
  • Oklahoma
  • Texas
  • Wyoming

While both the Parity Law and the Affordable Care Act guarantee treatment for substance abuse, there are some exceptions and loopholes in the laws. More clarification is needed in order to ensure that no one is denied treatment. Talk to your insurance company (either private or federally funded) to see what treatment options you have. In addition, the amount of coverage for addiction treatment included in any health insurance plan will vary widely from company to company and from state to state, so make sure to ask your insurance company about the extent of the benefits you are entitled to. Questions to ask about your drug treatment coverage include the following:

  • Does my policy cover inpatient or outpatient treatment (or both)?
  • What is the limit on the number of days in inpatient treatment per year?
  • What is the limit on the number of visits in an outpatient treatment program?
  • Does my policy cover prescription drugs need to manage the detox phase of my treatment?
  • Does my policy cover any after-care treatment?
  • What mental health professionals are in my network of care?
  • What inpatient treatment centers are in my network of care?

Are Any Drugs NOT Included Under the Substance Use Disorder Provision?

Insurance companies will pay for the treatment of mental disorders that are included in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). This manual names and characterizes mental health problems recognized by the majority of health care and mental health care professionals in the U.S. It is also the handbook on which insurance companies rely to determine payment of services. In short, a disease in the DSM-5 will be covered by insurance. In the DSM-5, a section named “Substance-Related and Addictive Disorders” encompasses ten different classes of drugs that are considered SUD (substance use disorders). Ten classifications include the following:

  • Alcohol
  • Caffeine
  • Cannabis
  • Hallucinogens
  • Inhalants
  • Opioids
  • Sedatives
  • Hypnotics
  • Tobacco
  • Other (or unknown) substances

Virtually every drug that addicts struggle with is included under these ten classifications of drugs ensuring that you can get help for your addiction no matter what drug you are addicted to.

Is Anything Else Covered Under the “Addictive Disorder” Umbrella?

In the DSM-5, the only other type of addictive disorder recognized and covered by insurance is gambling addiction. Unfortunately, no other type of addictive behavior, such as pornography addiction or Internet addiction, is recognized by the DSM-5, so they are not covered under insurance. However, if you are struggling with other types of addictions, there are other payment options you can explore, such as getting help from family or taking out a loan. The important thing is to get help.

Getting Help for Your Addiction to Drugs

If you or someone you love is struggling with an addiction to drugs like painkillers, we can help. You can call our toll-free helpline any time, 24 hours a day. You can talk with one of our admissions coordinators about your problem, and together you can determine the best course of action for treatment. We can even check your insurance benefits to see what kind of treatment is covered. Don’t let your addiction control you anymore. Call us today, and get the help you need.

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