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 may not cover intensive outpatient, partial hospitalization and residential treatment services. Plans may exclude methadone treatment for opioid use disorder treatment, even though such exclusions may violate federal law. 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. If it seems like your plan may be unfairly limiting benefits or it is otherwise difficult to get mental health or substance use care through your health plan, make sure you contact the U.S. Department of Labor or your state’s insurance department so they can investigate.
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:
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.