Open Enrollment is Here: Don’t Miss a Chance to Change Your Addiction Treatment Benefits

open enrollment Nov 1 - copyright

Fall is Open Enrollment season. Between November 1, 2019 and December 15, 2019, 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, here are a few things to keep 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 the 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.

Understand Which Doctors Are Covered By Your Plan

It is also important to think about which health care professionals the plan will allow you to see. If your plan is a Health Maintenance Organization (HMO), you can only see doctors or health specialists who are on the HMO’s list of participating providers. With a Preferred Provider Plan (PPO) or Point of Service Plan (POS), you can get treatment from out-of-network doctors and facilities, but often with higher out-of-pocket costs. If you have established relationships with your doctors and want to change health plans, check and confirm whether your doctor participates in the plan. It is always best to call the provider’s office to confirm plan participation, as the plan’s list of participating providers may be out of date. Obtaining services from providers and facilities that participate with your plan will help control your out-of-pocket costs.

Confirm the 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.

Don’t Wait – Act Now

Premiums, benefits and cost-sharing obligations often change from year to year, so it is important to review the terms of your coverage for the new plan year and compare other available options.

Learn more and register on >>

Demand Insurance Coverage for Addiction Treatment

Learn more about the Parity Act and why you’re entitled for addiction and mental health benefits that are equal to other medical/surgical benefits.