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What the Affordable Care Act Means to the Treatment Industry

The Affordable Care Act — the ACA, for short — was signed into legislation under President Obama’s administration in March of 2010 as a means to improve access to health care and affordable medical insurance options for American citizens.

What Has the ACA Changed?

Health insurance plans under the ACA now include a far wider range of benefits at often lower rates. More people will be able to get medical treatment than ever before due to the ACA expanding the reservoir of providers and the number of people who are insured by private companies and Medicaid. This means big changes for those who need addiction treatment services, a reported 22.7 million in 2013, per the Substance Abuse and Mental Health Services Administration.

The American Psychological Association points out that with ACA rules in place, lifetime and annual limits on policies are a thing of the past, and retroactive cancellation and the denial of coverage for pre-existing conditions are now prohibited, too. In addition, as of January 2015, Medicaid has been expanded in 29 states for residents with income below 138 percent of the federal poverty level, the Henry J. Kaiser Family Foundation reports. In remaining states, the limit is set at 46 percent, and adults with no children are entirely excluded from Medicaid eligibility.


The biggest expansion in conjunction with the ACA is the Mental Health Parity and Addiction Equity Act. The Act ensures that insurance companies must offer mental health and addiction rehabilitation services at costs that are comparable to other typical medical and surgical fees. Types of addiction and mental health treatmentservices covered by ACA plans include:

  • Outpatient and inpatient professional services, including commonplace services like detox and follow-up care
  • Visits for medication checks
  • Diagnosis and treatment of mental illnesses, inclusive of individual and group therapy and psychological tests
  • Family counseling
  • Convulsive therapy treatment


Of course, there are limitations. For example, just because an addict can now afford the price of insurance to treat their substance abuse problem, it doesn’t mean there will be adequate services available to service them. Many treatment centers were consistently at full capacity prior to the ACA going into effect. That being said, expansions for treatment through regular physicians are a great alternative most any patient can take advantage of should adequate treatment not be available to them otherwise. While only around 13,000 treatment providers were available in the past, the ACA opened the door to 550,000 physicians, as well as nurse practitioners and the like, who can now treat patients for substance abuse, the Partnership for Drug-Free Kids states.

Another downside is an age-old federal law that prohibits treatment facilities with more than 16 beds from billing Medicaid for treatment provided to low-income patients. With no plans to alter this longstanding legislation, the future for substance abuse treatment among Medicaid patients looks a little grim. Thus, Medicaid recipients may still be turned away time after time. Needless to say, a large number of the patients who need addiction rehabilitation the most are living in poverty and may very well be Medicaid recipients because of it. The Substance Abuse Policy Research Program attests to around 20 percent of all people on welfare using illicit substances every year.

Unfortunately, in states where Medicaid has not been expanded, there is room for a treatment gap to form. Many providers do not accept Medicaid due to its lower reimbursement rates, and therefore, there will be more patients than ever before trying to been seen by the same number of providers there has always been. Thus, in those states, some will and have ended up paying for coverage that they don’t actually have access to. The same problem will apply to Medicare recipients in need of mental health services as just a mere 54.8 percent of psychiatry professionals were accepting Medicare in 2010, the American Society on Aging reports.

Of those mentioned to be in need of treatment in 2013, only 2.5 million actually got it, SAMHSA reports. There is hope that these numbers will increase in the years to come with more and more patients having health insurance. The National Association of Americans with Disabilities Act Coordinators reports that around 32 million people were without health insurance prior to the ACA and around 5 million of them met the criteria for a substance use disorder diagnosis. Drug War Facts notes that 37.3 percent of people who needed treatment but didn’t receive it between 2010 and 2013 reported the reason being an inability to pay for the services and not having health insurance coverage. In 2011, 59.6 percent of all individuals aged 26 and older who were admitted to addiction treatment facilitiesdid not have health insurance; 21.3 percent had Medicaid, and 10.5 percent carried private insurance policies, per SAMHSA

Mental Health Accessibility

Another big perk of the ACA in the addiction treatment community is the added bonus of more access to and affordability of mental health care. Mental health is an overwhelmingly large issue for many addicts who have no hope of living a normal life without substance abuse until their mental health issues are treated. Helpguide states 29 percent of the mentally ill population are substance abusers. According to the Office of the Assistant Secretary for Planning and Evaluation, 25 percent of uninsured Americans have a mental health disorder, substance abuse disorder, or both. Elaborating on that, the Fiscal Times reports 60 percent of adults and 70 percent of children with mental health disorders were not being treated as of 2011 — numbers that the ACA aims to change.

What You Need to Know

Whether you’re just shopping for new insurance or you’re trying to figure out what your existing plan can do for you, there are a few components of every insurance plan you should go into the process understanding. First and foremost, all health insurance plans come with a deductible, which is the amount you must pay toward your medical expenses before your insurance carrier will pay for covered services.

Every plan should clearly outline which services require you to pay toward your deductible on them and which do not. Some services are completely covered while others may require you to pay as much as 20-30 percent or more. When you’re considering addiction treatment, you need to be aware of how much your annual deductible is and how much you still owe on yours for the year so you aren’t caught off guard when it comes time to pay for treatment. You’ll pay a premium each month toward the cost of your insurance plan.

Verification might be the most confusing part of the ACA eligibility process for most applicants, but luckily, there are customer support agents readily available to assist around the clock. Eligibility and prices for plans you qualify for are based on your location, household size, and income. Tax credits and monthly discounts apply to certain demographics that fall within set income ranges based on household size, but should you make more or less in a given year than predicted, credits and discounts could be changed retroactively.

Those who might be eligible for Medicaid will have to go to even greater lengths for verification by providing documented proof of monthly income and bills. According to the Wall Street Journal, some 6 million people had received Medicaid by April of 2014 as a result of applying through the ACA’s health care exchange, bringing the total Medicaid tally to 65 million. Coinsurance, or co-pays for short, are the portion toward a given service you must pay. On average, this payment is 10 percent of the service or about $25 for most plans which apply an 80/20 rule in majority, but they can vary and be as much as a 50/50 split.

Another consideration you must make are your out-of-pocket expenses. These limits are the minimum you must pay and the maximum you ever will pay in one year before your insurance carrier starts to pay all of your covered essential health benefits. According to, the limit for individuals in 2015 can be no more than $6,600 and for families, no more than $13,200. Out-of-pocket costs include your deductible, coinsurance, and any other fees you pay toward your plan. Furthermore, if you’re planning to travel for substance abuse treatment, you’ll need to confirm your geographical treatment area and make sure the facility you choose is in your provider network for the best possible rates.

Are You an Addict?

Suspecting addiction is enough to warrant being screening. Start here:

  • Have you developed a tolerance to alcohol or drugs that requires you to keep upping your dose?
  • Are friends and loved ones complaining that they never see you anymore because you’ve withdrawn to spend time using instead?
  • Can you feel withdrawal symptoms setting in if you stop using?
  • Have you attempted to quit and failed?
  • Have legal, financial, or interpersonal issues stemmed from your substance abuse habits?
  • Do you find yourself thinking or obsessing about the next time you’ll drink or use drugs?
  • Are you preoccupied with making sure you always have an adequate supply?

If any of the above warning signs are present in your life, it’s time to start looking for professional help.

Helping You Get Help

Treatment is now within reach for hundreds of thousands of addicts that wouldn’t otherwise have been able to afford it just a year or two ago. The hope is that those individuals will now seek the help they need and that others will follow suit for years to come. Forbes Magazine reports that an approximate 11.4 million people are enrolled for insurance through the marketplace for 2015 coverage. For more information on insurance coverage and corresponding treatment facilities, reach out to us today via our toll-free number.

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