EXECUTIVE SUMMARY
Insurance coverage for opioid addiction treatment can vary depending on the specific insurance plan, provider, and location.
However, there have been significant changes in recent years to improve access to Treatment for opioid addiction due to the opioid epidemic in the united states.
At the federal level, for example medicaid serves over 72 million adult and child beneficiaries annually (centers for medicare & medicaid services or cmcs). An estimated 12 percent of adults over 18 years of age and 6 percent of adolescents aged 12 to 17 years in medicaid and have a substance use disorder.
At the state level, for example in Connecticut, to learn about your potential federal and state health insurance benefits to treat opioid addiction in your family, be sure to update your name, address, and phone number at ct.gov/UpdateUsDSS.
Here are some general points to consider:
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT (MHPAEA):
This federal law requires that insurance plans cover mental health and substance use disorder services at the same level as medical and surgical services.
This means that insurance providers must provide equitable coverage for addiction treatment, including opioids.
2. IN-NETWORK AND OUT-OF-NETWORK COVERAGE:
Check if the addiction treatment facility or healthcare provider is in-network with your insurance plan.In-network providers typically have lower out-of-pocket costs compared to out-of- network providers.
3. COVERAGE FOR DIFFERENT LEVELS OF CARE:
Insurance plans may cover various levels of care, including detoxification, inpatient rehab, outpatient rehab, and medication-assisted treatment (MAT) such as methadone or buprenorphine.
Be sure to understand what types of treatment your plan covers.
4. PREAUTHORIZATION AND MEDICAL NECESSITY: Some insurance plans may require preauthorization or proof of medical necessity for opioid addiction treatment.
This means you may need to demonstrate that the treatment is medically necessary for your condition.
5. COST-SHARING: Review your insurance plan's cost-sharing structure, which includes factors like copayments, deductibles, and coinsurance.
Different plans will have different cost-sharing requirements.
6. LIFETIME AND ANNUAL LIMITS:
Some insurance plans used to have limits on the duration and total amount of coverage for addiction treatment.
However, the Affordable Care Act (ACA) prohibits these lifetime and annual limits for essential health benefits, which include addiction treatment.
7. STATE AND FEDERAL PROGRAMS:
In addition to private insurance, there may be state-funded programs or federal programs like Medicaid that provide coverage for addiction treatment.
8. OUT-OF-POCKET EXPENSES:
While insurance can cover a significant portion of addiction treatment costs, you may still have some out-of-pocket expenses. It's essential to understand these costs and plan for them.
9. CONTINUITY OF CARE:
If you're already in treatment for opioid addiction and switch insurance plans, inquire about continuity of care to ensure that your ongoing treatment is not disrupted.
10. NETWORK PROVIDER DIRECTORIES:
Check your insurance provider's network directories to find healthcare facilities and professionals specializing in addiction treatment.
To navigate the complexities of insurance coverage for opioid addiction treatment, it's advisable to contact your insurance company or work with a healthcare professional who can assist you in understanding your specific policy and available treatment options.
Additionally, consider reaching out to local addiction treatment centers for guidance and assistance in determining your best course of action.
SOURCE: ALLEN RESEARCH ENDOWMENT, INC.
Medical Disclaimer. The information contained herein is for educational and informational purposes only and does not constitute medical advice or a patient-client relationship with Allen Research Endowment, Inc. You must consult with your own physician or other healthcare professional regarding this information and your own unique needs. Information based on data we believe to be reliable. However, we cannot guarantee its accuracy. Information subject to change without notice.\
Allen Research Endowment is focused on saving lives of people with opioid addiction through treatment, prevention, and research to develop non-opioid pain management solutions. https://www.allenrsch.org. admin@allenrsch.org. © 2023 Copyright Allen Research Endowment, Inc.
