Last updated: 04/2/2019
Author: Addictions.com Medical Review
Reading Time: 5 minutes
With rates of addiction steadily climbing, the addictions field has had much to work with over the past decade. Likewise, the definition of addiction has undergone some radical changes within the eyes of the law. These developments have brought about new healthcare legislation that greatly benefits addicts who want to enter drug treatment.
The high costs of heroin addiction treatment can be a formidable obstacle to getting needed treatment help for many people. According to the Office of National Drug Control Policy, under the Affordable Care Act of 2014, people in need of heroin addiction treatment or addiction treatment in general can now use their existing healthcare coverage to cover treatment costs.
Types of Heroin Addiction Treatment
People enter heroin addiction treatment at various points along the drug abuse continuum. While some may only struggle with physical dependency or mild addiction problems, others may be battling severe addictions.
For these reasons, heroin addiction treatment programs can vary in terms of treatment duration, services offered and level of addiction treated. All of these factors play into how much any one program will cost.
The various types of heroin addiction treatment programs include:
- Detox care
- Inpatient treatment
- Outpatient treatment
- Residential programs
- Sober living programs
In general, programs offering the most intensive treatment are the most expensive. This includes detox, inpatient and residential programs. Outpatient and sober living programs run longer in duration, but offer a less intensive or structured treatment approach in terms of not requiring patients to live at the facility.
The types of programs you’re considering will likely have a bearing on how much insurance will cover.
Heroin Addiction Treatment: An Essential Healthcare Benefit
The Affordable Care Act of 2014 or ACA makes provisions for a range of healthcare benefits that were previously unavailable, one of which being coverage for substance abuse treatment. According to Healthcare.gov, the ACA redefined the parameters of what’s considered an “essential health benefit.” These changes account for the insurance options now available to cover heroin addiction treatment.
As an essential health benefit, heroin addiction treatment falls under the mental and behavioral health services category, one of 10 eligible categories. Consequently, any services that qualify as an essential health benefit are not subject dollar limits in terms of yearly or lifetime caps.
While the Affordable Care Act does offer certain provisions and protections from a federal standpoint, each individual state further defines what types of services are covered by a standard insurance plan.
The Mental Health Parity and Addiction Equity Act
The Mental Health Parity and Addiction Equity Act exists as an adjunct to the Affordable Care Act, implementing certain parity provisions for healthcare coverage benefits. According to the Centers for Medicare & Medicaid Services, parity protections work to ensure that all marketplace plans offer the same level of benefits across the board in terms of medical/surgical benefits versus mental and behavioral health services benefits.
Under these provisions, benefits offered under the mental and behavioral health services category cannot be more restrictive than limits applied to medical/surgical benefits. In general, parity protections for heroin addiction treatment encompass the following areas:
- Treatment limits, in terms of number of visits or number of days covered
- Financial limits, in terms of copayment, coinsurance and deductible amounts as well as out-of-pocket limits
- Care management, in terms having to get authorizations for treatment from physicians
Before the enactment of the Affordable Care Act, insurance plans offered fewer benefit coverages, as well as lower coverage amounts, for mental and behavioral health services compared to medical/surgical services. Part of the reason for this change has to do with addiction’s formal classification as a chronic brain disease. This new classification places heroin addiction treatment in the same category as diabetes and heart disease treatment as far as overall health risks go.
Types of Insurance
The combined protections provided by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act apply for all types of insurance plans. In this respect, insurance companies no longer have the option of offering or excluding certain types of benefits on a standard issue insurance policy.
These measures extend to all types of insurance coverage, including:
- Employer Plans
- TRICARE (military health coverage)
- Individual coverage plans
- Medicaid/Medicare coverage
This means, anyone who has a standard insurance policy can use it to pay for some or all of his or her heroin addiction treatment costs.
Group Insurance Option
Group or employer-sponsored insurance plans offer a range of coverage allowances for heroin addiction treatment. Anyone who’s currently covered under an employer health plan can use it towards his or her heroin addiction treatment costs.
According to the Substance Abuse & Mental Health Services Administration, available benefits for heroin addiction treatment should be no different than those offered for medical care or surgery-related benefits. This includes:
- Levels of treatment, in terms of inpatient versus outpatient treatment
- Benefit coverage for out-of-network providers
- Limits on treatment duration
- Out-of-pocket costs and caps
Government-Sponsored Insurance Options
While employer-sponsored healthcare can go a long way towards paying for heroin addiction treatment, it’s not uncommon for addicts to lose their job as a result of an addiction problem. Likewise, people who’ve since retired from the workforce lose the security of an employer-sponsored health plan.
Fortunately, government-sponsored insurance options, such as Medicaid and Medicare can pick up where employer-sponsored plans leave off. As Medicare falls solely under federal jurisdiction, standard benefit allowances apply for heroin addiction treatment. On the other hand, Medicaid receives funding from both state and federal governments, so benefit allowances can vary depending on your state of residence.
It helps to keep in mind that not all drug treatment programs accept Medicare and/or Medicaid, though many of them do.
Unless your employer offers top-notch health insurance coverage, it’s likely your insurance plan will only cover a portion of your heroin addiction treatment costs. Considering how expensive healthcare coverage is, even out-of-pocket costs can bankrupt a household budget when extensive treatment is needed.
Under these conditions, it may be a good idea to look for treatment programs that offer sliding-fee scale payment arrangements. In this way, any out-of-pocket costs can be paid off over time rather than all at once.