Get Support
Fall is Open Enrollment season. Between November 1 and December 15, individuals who buy their health insurance on the federal or state health insurance marketplaces have the opportunity to change plans. Many employers also hold open enrollment in the fall, so individuals who get their insurance through their employer also have an opportunity to change their health plan.
If you or someone on your plan requires addiction treatment services, keep the following in mind.
Know your options
Review your plan options carefully to determine whether you will be able to obtain the services you need. Most plans offered on the health insurance marketplaces must offer addiction treatment benefits, although which services and medications are covered varies by state and by plan. Some plans do not cover intensive outpatient, partial hospitalization and residential treatment services. Plans often exclude methadone treatment for opioid use disorder treatment. If you or someone on your plan needs a specific service, make sure it is covered by the plan you select. Look out for any limits on the number of days or episodes of treatment that are covered and take note of out-of-pocket expenses. In general, the longer people stay in treatment, the better their chances for recovery. Inpatient or residential stays should always be followed by outpatient treatment for some period of time.
If you get your insurance through your employer, your plan may not be required to cover addiction treatment benefits. Nonetheless, most public and private plans are subject to the Parity Act, a federal law that requires plans to cover mental health and substance use disorder treatment the same way they cover treatment for other medical/surgical benefits.
Be aware of costs
Going with the cheapest plan isn’t always the best deal – you have to add up your out-of-pocket costs plus your monthly premium payments in order to find the plan that is most affordable for you. Below are some tips to help you assess your needs:
- Understand the copayment costs. For inpatient admissions, including residential treatment, you may be subject to very high copayments, especially in plans that charge lower monthly fees.
- Be aware of facility copayments for intensive outpatient services. Some plans will charge a fee in addition to copayments for physician services.
- Speak with your provider about the types of services you need and ask if the plan will cover them. This can help you estimate your out-of-pocket expenses.
- Take note of deductibles (the amount you must pay out-of-pocket before your plan begins to pay) as well as the types of services that count toward your deductible.
- Review plans carefully and contact a marketplace representative in your state for assistance.
- Learn about and anticipate the financial costs. There is enough stress to cope with during early recovery; don’t add unexpected financial strain to the list of things you will have to deal with.
Confirm medications included in your plan
Remember to confirm whether the plan covers any prescription drugs you will need. Plans sold on the health care marketplaces must cover at least one medication for alcohol dependence, opioid dependence, opioid reversal and smoking cessation. Make sure that the specific medication you need is on the plan’s list of covered drugs (also known as the “formulary”) and check how much it will cost you out-of-pocket.
Also, be aware of any requirements for prior authorization or step therapy, which may require you to try less expensive versions of your medication before a more expensive version will be approved. You may need to get specific documentation from your doctor in advance and have any necessary paperwork completed to avoid interrupting your medication.