The Affordable Care Act, also known as Obamacare, ensured that healthcare providers must provide basic health benefits (essential health benefits) as part of their overall services. This includes coverage for basic services, including mental health treatment. Treatment for substance use disorders falls under the rubric of mental health and behavioral health treatments that are guaranteed by the ACA. Therefore, insurance providers must provide some level of coverage for treatment of substance use disorders, and this coverage must be equivalent to the types of services that are covered for primary care.
While insurance plans must provide some type of coverage for the treatment of substance use disorders, the Affordable Care Act does not specify the exact amount of coverage that must be provided, only that it must be equivalent to services that are provided for primary care issues. The actual amount of coverage an individual will receive depends on their insurance company, the state they live in, and the particular plan they have.
Aetna, Inc. is an American-based managed healthcare company that was founded in 1853. The company descended from the Aetna Fire Insurance Company of Hartford, Connecticut, which got its name from Mount Etna, an active volcano in Europe.
The company markets traditional and consumer-directed healthcare insurance plans and other services, such as pharmaceutical, dental, and disability plans. The company offers coverage to over 20 million Americans and has nearly 50,000 employees. Even though Aetna abides by legislation under the Affordable Care Act, it has withdrawn most of its participation in the Marketplace.
Aetna offers extensive coverage for substance use disorder treatment, including inpatient and outpatient rehabilitation. According to information from its website, the company suggests that policyholders contact a customer representative to discuss substance use disorder treatment. Members have support seven days a week, 24 hours a day, and support staff can help clients find a particular rehabilitation center or physician.
The company reports that it prefers the use of private therapy and 12-Step group participation in addition to medical management of issues with substance abuse, although other services are also covered. The length of treatment that is allotted in specific cases depends on the individual’s plan. The coverage can extend to most inpatient and outpatient treatment, depending on the particular case and the determination of medical necessity for the treatment.
An alternative to contacting Aetna directly is to contact intake personnel at a particular treatment facility. Intake advisors can very quickly determine if the services provided at the facility are covered by the individual’s insurance and can discuss all of the nuances with an individual’s insurance representative. Sometimes, intake personnel are more efficient at getting services approved for potential clients than customer service representatives at insurance corporations.
Services Provided at In-Network vs. Out-of-Network Providers
Aetna offers numerous insurance plans to fit a variety of needs. These plans have different deductibles (the amount individuals must pay out of pocket before insurance begins to cover expenses), different limits, and different rates for providers. For instance, if an individual has a $2,000 deductible, they pay the first $2,000 of their medical expenses before the insurance plan begins to provide coverage. After the deductible has been met, specific plans have various copays (amounts individuals are required to pay) and percentages of coverage (the amount the insurance company will cover) given the service provided, the provider, etc. A list of the general type of plans that Aetna offers can be found here.
Aetna reports that it covers withdrawal management services (detox services), residential treatment, inpatient treatment, partial hospitalization treatment, and intensive outpatient treatment programs. Aetna also covers costs associated with psychotherapy and counseling applied to mental health disorders.
Precertification is required for some services to be covered. Based on information on its website, these services include:
- Admission to an inpatient or residential treatment center
- Partial hospitalization treatment (treatment occurs in a hospital setting but the patient is not housed in the hospital)
- Intensive outpatient treatment
- Outpatient withdrawal management programs
- Any psychological tests for assessment purposes
- Biofeedback (e.g., neurofeedback)
- In-home psychiatric services
Aetna also covers expenses associated with treatment services administered by in-network providers (those in the Aetna network of treatment providers) and providers that are outside the network. However, individuals should consider using in-network providers as the coverage is far more extensive. For example, Aetna will often cover up to 80-90 percent of the charges incurred with providers within their network, whereas they are more likely to cover only 60 percent or less of charges incurred from out-of-network providers. In addition, in-network providers are typically less expensive than out-of-network providers, making the savings even more dramatic as a result of copays.
How Coverage for Substance Use Disorder Treatment Is Determined
The services covered by Aetna and the amount of coverage offered are determined by numerous factors, such as:
- The medical necessity of the treatment: Medical necessity refers to the treatment being required for the specific condition as opposed to it being preferred by a physician or patient. Insurance companies have guidelines to determine the medical necessity of specific treatments. For instance, inpatient withdrawal management services would most likely not be approved for someone who abuses cannabis products except under very extreme conditions or circumstances, whereas an individual who abuses opiate drugs would be far more likely to have the services approved. While insurance companies have specific guidelines to determine the medical necessity of specific treatments for specific types of conditions, a well-written referral from a physician can also contribute to specific services being labeled as medically necessary for an individual.
- Empirical evidence: Treatments that have empirical evidence to support their success in treating a particular condition are more likely to be covered. Empirical evidence refers to research findings.
- Appropriateness for treating the condition in question: This particularly applies to medications. Medications used during medical management for individuals with substance use disorders will often only be covered if the medications are designed to treat issues with substance abuse. Typically, insurance companies rely on well-established research findings to determine this. Medications used on an off-label basis are less likely to be covered.
How Can One Pay for Services That Are Not Covered?
For many individuals, paying deductibles, copayments, etc., is quite burdensome. Many rehabilitation facilities will set up payment plans to make this more manageable. This often involves clients making monthly payments. In some cases, treatment facilities may offer scholarships or make special arrangements in cases of financial hardship.
In addition, some people may be able to borrow money from friends, a bank, or some other institution to cover deductibles, copays, and other expenses that are associated with treatment for a substance use disorder. Although this may seem like an odd way to use credit, a solid treatment program for a substance use disorder is well worth the investment
Click below to learn about some of the major insurance providers with policies that may cover drug treatment or ancillary services.