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Affordable Care Act expands coverage for addiction treatment

by Take Two®

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Drug treatment experts and public health officials said they see an increase in heroin use that is accompanying a rise in prescription opioid abuse by young people. A report released by the L.A. Department of Public Health Monday said drug overdose is the third leading cause of death and injury in the county. Daniel Anderson/California Watch

The death of actor Philip Seymour Hoffman has focused national attention on addiction issues and how things are changing under the Affordable Care Act.

On January first, the federal law expanded coverage for treatment of drug and alcohol addictions. We have KPCC Health Care Correspondent Stephanie O’Neill here to fill us in on all of this. Hey Stephanie…

TT: So there are some changes now happening…but to put it in perspective, can you tell us a bit about the addiction treatment landscape before the New Year rolled around?

SO: Before the Affordable Care Act took effect, about a third of those who bought a health plan in the individual market had no coverage for addiction treatment, according to Health & Human Services.

Then, even when a plan did provide the coverage, it was typically with more financial and other restrictions than was required for medical and surgical care. So the addiction coverage lacked what’s known as “parity” with treatment for medical issues.

TT: And now, things have changed…. Under Obamacare, I understand that a lot more people will have access to substance abuse treatments.  Tell us about that.

SS: Right. There are two big factors that are greatly expanding addiction coverage nationwide.

First: As of New Years Day, the individual market health plans and the small group health plans sold inside and outside the state run marketplaces -- are required to provide ten Essential Health Benefit categories – which include care for substance abuse.  And in addition to the requirement that the plan provide it to consumers, …because it’s classified as an “essential health benefit” an insurer cannot impose an annual or lifetime limit on how much they’ll pay for that treatment – as long as the treatment is deemed medically necessary.

Second: The plans are now governed by a federal law called the Mental Health Parity and Addiction Equity Act of 2008.  That law requires health plans that cover addiction treatment – which again is all the new plans under the ACA - to cover it to the same extent that they cover a patient’s medical and surgical needs. So that means an insurer can’t impose stuff like higher copays or cost sharing on addiction coverage than they would for medical coverage under the same policy. And it also means that plans must use the same prior authorization process for substance abuse treatment as they would for medical services. So one can’t be more restrictive than the other.  

TT: Which addiction services are now covered through insurance plans sold in California?

SO: In California, the coverage includes both inpatient and outpatient services – so inpatient detox at a residential facility is included. Then there’s outpatient care such as day-treatment; intensive outpatient programs – those are programs that serve a patient three hours a day, at least three days a week; then there’s individual and group counseling and medical care for withdrawal symptoms. So those are the broad categories of service and then within each category the insurer gets to determine the specifics, like which providers they send consumers to, which treatment centers and the brands of medications they cover. 

TT: Any idea how much someone would pay for these services?

SO: That will vary. The amount you’ll pay for deductible, co-payments and other cost-sharing for the treatment will depend on the metal tier of the insurance plan you choose – from the lowest-end Bronze plan to the highest end Platinum plan, which has the highest monthly premium.Generally, the higher the tier – like gold or Platinum - the less the consumer will pay for the substance abuse treatment.

TT: What about people on Medi-Cal?

SO: Under the ACA, you’re eligible for Medi-Cal if you make less than about $16,000 a year.

And under Medi-Cal, there’s a separately-funded program for substance abuse that’s known as D-M-C, which stands for Drug Medi-Cal. So if a doctor first determines that a Medi-Cal enrollee needs such care, the person would then be sent for treatment to one of more than 1400 Medi-Cal certified treatment facilities statewide.

Some of the new benefits offered through D-M-C include inpatient detox; residential treatment, methadone maintenance, and outpatient counseling.

TT: Is there a limit to how much care a person can get in the Drug Medi-Cal program?

SO: The way it works is the patients will receive services for up to six months…and if the counselor or doctor determines that it should last longer, they need to document that for every additional six month-period. So it can go for substantially longer than a year, if needed.  

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