Receiving treatment for substance use disorder (SUD) is not as simple as walking through the front door of a mental health facility. The cost of treatment is a major barrier that can create hesitancy even if you are a motivated patient.
The Crisis of Healthcare Costs
The American healthcare system can bury you in hospital bills.
You may find yourself having to decide between receiving necessary medical treatment and paying rent or buying groceries. Perhaps you worry about the burden of debt on your family.
Now you understand the phrase, “I can’t afford to be sick.”
The cost of medical care combined with the stigma around mental illness can deter you from getting help with your SUD. Yet, leaving a problem to fester frequently makes it worse—and therefore more expensive — later on. It is better to solve the problem as soon as possible.
If you require treatment for SUD, you may wonder how you are going to pay for it. It may seem too expensive to get better. Luckily, if you have insurance, some of the costs may be covered. Examining the Affordable Care Act (ACA) can help you discern whether an insurance company will pay for your detox and rehab.
Mental Health Protections Under the Affordable Care Act
In the United States of America, the Patient Protection and ACA regulates insurance companies. There are ten categories of required coverage listed under the ACA, including mental health and substance abuse treatment. As such, your insurance plan must provide a certain threshold of care.
Access to preventative care is a cornerstone of the ACA. Insurance companies must provide preventative procedures and care for free. This includes mental health screenings. Therefore, you are entitled to mental health screenings when visiting your general practitioner (GP). You will not be charged for this service, only the normal copay for a GP visit.
Furthermore, services like therapy, inpatient behavioral health services, detox, and other mental health care cannot be restricted more than other medical care. Lifetime and yearly financial limits cannot be placed on essential mental illness or substance use treatment assistance. You also cannot be denied coverage based on pre-existing mental disorders or have your plan canceled for using your benefits.
You are also guaranteed access to mental health medications. While the ACA does not set prices, it can enact restrictions to prevent price gouging on mental health prescriptions. Insurance companies cannot charge a different amount for these medications than other prescriptions within the same tier.
Understanding your insurance benefits and knowing your rights under the ACA can help you make sure you are getting the best, most affordable care available to you.
Limitations and Loopholes
While insurance companies must cover mental health and substance abuse care due to the ACA, they frequently find loopholes to make coverage more difficult. For instance, they may charge high copays which creates a barrier for those who struggle to make ends meet.
Additionally, you may only be able to see a small number of “in-network” providers. Due to the high quantity of people needing care and the mental health providers’ limited hours, you may wait weeks or months just to get a single appointment.
The same goes for detox and rehab. You may only be able to attend specific facilities if you want insurance coverage. The oversaturation of patients, especially given the COVID-19 global pandemic, means you may have to wait long periods to enter. If you cannot, you might have to pay out of pocket.
Insurance companies can make the process more complicated than necessary. They may not deny care, but they frequently draw out the steps you must take. Often, you must see your GP for a referral to a mental health specialist (e.g. psychologists, counselors, psychiatrists) who can refer you to a substance abuse facility or program. If you do not see your GP first, you could be denied coverage altogether.
Similarly, an insurance company might demand a second or third opinion to prove the necessity of your mental health care. Your care could be delayed based on which diagnostic code is used. Your insurance provider may demand a prior authorization for any facility stay.
All of these methods are used to wear you down. They want you to withdraw your request for care, so they do not have to pay. It is important to be aware of these tactics so you will not fall prey to them. When you pay for insurance, you are entitled to good health care at a reasonable price.
Assert Your Rights
If you find yourself in a situation where the ACA is being violated by your workplace insurance company, assert your rights by submitting a complaint to the Occupational Safety and Health Administration (OSHA). This can be done virtually on the OSHA website. Employers cannot retaliate against whistleblowers who report violations.
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