Marketplace Coverage for Rehab - ACA & PPO - The Discovery House

Marketplace Coverage for Rehab

What You Need to Know About Marketplace Coverage for Rehab

It is estimated that less than ten percent of  Americans who need substance abuse treatment actually receive it. While there are many barriers to treatment, one issue is the lack of affordable or easily accessible treatment options. So, what is the actual marketplace coverage for Rehab in the USA?

However, it’s not as difficult as it used to be to get treatment. As a result of the passing of the Affordable Care Act (ACA), more Americans have access to health insurance plans that cover addiction treatment.

Even though the Act which is also known as Obamacare was passed in 2008, most of the major provisions came into effect in 2014. This was when individuals began accessing the health insurance marketplace which we’ll discuss here.

Under the Act, every health insurance plan must offer ten essential health benefits including mental health services. This allows many people who previously couldn’t access addiction treatment services to get the care they need.

Let’s take a closer look at the marketplace and how it can help you or a loved one to get substance abuse treatment if you need it.

What is the ACA Marketplace?

What is the ACA Marketplace

The Health Insurance Marketplace is an online resource found at that allows individuals, families, and small businesses to:

  • Find out if they’re eligible to get tax credits for Medicaid or private insurance 
  • Compare health insurance plans
  • Enroll in a plan that meets their needs
  • Get answers to questions about their insurance

Some states also have their own separate Health Insurance Marketplace. The differences between federal and state plans are dependent on the Medicaid and Medicare coverage in each jurisdiction.

Marketplaces or exchanges offer various options for health insurance policies that are subsidized by either the government or private companies. When individuals sign up, they can see the plans for which they’re eligible.

These plans help to reduce the cost of insurance premiums. While people can change their plans whenever they want, eligibility status and costs may also change. Even if your home state has a marketplace, you can shop in the federal marketplace.

When you get insurance in the exchange, you receive certain protections. For example, you can’t be denied coverage or charged higher premiums because of pre-existing conditions including mental illness.

Also, insurance policies in the healthcare marketplace can’t impose a coverage limit in terms of dollars spent on treatment. Other policies have caps on dollars or days used for treatment.

The marketplace also offers protection for mental health services inclusive of the number of visits covered, deductibles, and copays.

What Does ACA or Obamacare Insurance Cover?

Prior to the passing of the ACA, insurance companies treated addiction as a pre-existing condition. This is no longer the case and coverage for addiction treatment needs to be as wide-ranging as it is for any other type of medical treatment. Insurance providers in the marketplace need to cover:

  • Alcohol and drug testing 
  • Clinic visits
  • Evaluations for addiction
  • Medical detox
  • Addiction treatment medication
  • Medication to prevent cravings
  • Counseling 

As you can see, the Act treats addiction as if it were any other type of disease with attention being paid to prevention, early intervention, and multiple options for care. Before, many people who were addicted to drugs or alcohol only accessed treatment when it was absolutely necessary because they had hit rock bottom.

It’s important to note that even though insurance covers a wide range of services, most plans will require you to foot some of the costs out of pocket. The amount you will have to pay depends on which of the five types of ACA plans you have.

That’s why you need to talk to your insurer about which healthcare professionals are in your network, which treatments are covered, and how many times you can use a particular service.

The Five Types of Marketplace Plans 

The available plans are:

  • Platinum. Platinum plans usually have the highest monthly premiums and the lowest out-of-pocket costs. The individual pays about ten percent of their covered medical expenses while the insurance company pays the rest. 
  • Gold. With gold plans, the policyholder pays about 20 percent of their medical costs while the insurance company takes care of the other 80 percent.
  • Silver. Silver plans are often a bit more affordable where monthly premiums are concerned but out-of-pocket costs will be higher when you seek medical care. You’ll pay about 30 percent of your covered medical expenses while the insurer covers around 70 percent.
  • Bronze. With a bronze plan, you’ll be expected to pay for about 40 percent of your covered medical expenses and the insurance company will take care of the other 60 percent. Since you’ll pay more out of pocket when you seek medical care, your premiums will likely be lower. 
  • Catastrophic. Catastrophic plans cover many of the same benefits as other ACA plans.  However, they are only offered to people under the age of 30 or those who qualify under other special criteria. These plans have lower premiums but higher deductibles. 

The ACA provides government subsidies to qualifying individuals and families who earn up to 400 percent of the federal poverty level. These subsidies can make it easier for you to afford your health insurance premiums. Any of the five plans will protect you from a tax penalty but not all can be purchased with a subsidy.

Medicare, Medicaid, and the ACA

Medicare, Medicaid, and the ACA

People who are looking into marketplace coverage for rehab are often confused about the difference between the Affordable Care Act, Medicare, and Medicaid. The ACA is a set of regulations governing the health insurance industry. It isn’t an insurance plan but it did expand the Medicaid program.

Medicare and Medicaid have been around since 1965. They are funded at the state and federal levels and they both can cover addiction treatment. However, as you’ll soon see, they are not the same although it is possible for a person to qualify for both. Let’s take a look at some of the key differences especially as it relates to coverage for rehab and related services.

Medicaid Basics

Medicaid offers healthcare insurance to low-income individuals who earn at least 133 percent below the federal poverty level. People who are eligible for coverage include adults, children, older people, and people with disabilities living in the United States and its territories.

Medicaid is the largest source of health care coverage in the country. Each state has its own rules regarding eligibility and benefits so you’ll need to check your state’s policies if you want to seek out-of-state treatment. Medicaid covers the basic components of addiction treatment including:

  • Interventions
  • Screenings
  • Detox
  • Counseling 
  • Inpatient and outpatient care
  • Mental health services
  • Aftercare services

Medicare Basics

The Medicare program is designed specifically to assist people who are over the age of 65 or those who have severe disabilities. Unlike Medicaid, income is not a criterion for eligibility. Instead, this program is generally an option for people age 65 or older as well as individuals of any age with disabilities and those with End-Stage Renal Disease.

Medicare Part A covers hospital insurance while Part B covers Medicare insurance. You can get  Part A premium-free if you are age 65 or older and either you or your spouse paid Medicare taxes for ten years or more. You are also eligible to get Part A at age 65 without having to pay premiums if:

  • You get Social Security retirement benefits or Railroad Retirement Board benefits
  • You are eligible to receive these but you haven’t yet filed for them
  • You or your spouse had government jobs with Medicare coverage.

Medicare isn’t as broad-based as Medicaid so there are some limitations. However, Medicare covers both inpatient and outpatient substance abuse treatment. Medicare is broken down into four parts and each part covers a different aspect of rehab. 

Part A covers hospital stays, inpatient addiction treatment, hospice care, and other specialty health care. It also covers stays in semi-private rooms, meals, drugs,  and nursing and other hospital services.

It must be noted that Medicare doesn’t cover more than 90 days in any type of facility over the course of the covered person’s life. This means it may not be suitable for ongoing addiction treatment.

Part B covers preventative services, doctor’s visits, outpatient care, and medical supplies. Part C or Medicare Advantage offer  Medicare-approved private insurance plans. This is separate and optional and most Part C plans include Medicare Part D.

Part D of Medicare covers the cost of prescription drugs. If you enter drug addiction treatment, you’ll need this coverage for Suboxone or other maintenance medications which can be prescribed both during and after treatment. Since Medicare is strict about which aftercare medications can be used, it will only cover them if they are medically necessary.

PPO vs HMO and Other Terms to Know

PPO vs HMO and Other Terms to Know

As you search for the best insurance plan for you and your family, you’ll come across terms like PPO and HMO. It can all be very confusing but understanding the difference between the various types of plans can help you to make your decision.

HMO stands for Health Maintenance Organization. An HMO health plan is one where you pick one primary care physician (PCP) who acts as the conduit between you, your family, and your care.

To see another healthcare provider or get any type of health service outside of emergency care, you’ll need to get referrals. This often means that you’ll be operating within a very narrow network. However, out-of-pocket expenses are usually lower. If you go outside the network, your services won’t be covered.

Meanwhile, PPO stands for Preferred Provider Organization. A PPO health plan is one where the insurer allows several different health care providers to participate in the network.

You can choose a service provider in the network and unless a service is particularly expensive, you’re unlikely to need a referral. This allows for quicker and more efficient service. PPOs provide more flexibility than HMOs but your out-of-pocket costs are likely to be higher.

What’s Left Out of ACA Coverage?

There’s no doubt that the Affordable Care Act provides greater access to addiction treatment services. However, critics say it doesn’t guarantee high-quality care for people struggling with substance abuse problems. Some argue that many of the people who enter addiction treatment programs don’t receive science-backed, evidence-based treatment. 

Instead, they may enter facilities that reject scientific evidence and prohibit the use of medications to treat addiction. In some cases, people struggling with their addiction are encouraged to accept that they’re powerless or weak.

This is an approach which many addiction professionals say doesn’t work. Experts have recommended that insurance plans should only cover treatment programs that are based on science. This would help to ensure that people get adequate treatment for drug and alcohol addiction.

Discuss Your Options with the Team at The Discovery House

If you’re ready to seek treatment for drug or alcohol addiction, you shouldn’t have to worry about how you’ll pay for it. We accept most forms of PPO insurance but coverage will vary from one policy to another.

Some insurance companies only cover treatment providers who belong to their network while others may only pay for treatment of a certain duration. There are many variables at play but you shouldn’t let that deter you from inquiring about your options.

The list of PPOs we accept is always changing but it includes:

  • Assurant Health
  • Aetna Health Insurance
  • Blue Cross and Blue Shield
  • Healthnet
  • United Healthcare
  • Cigna Health Insurance
  • ValueOptions Behavioral Health Care
  • Humana
  • UPMC

If you don’t see your provider listed, contact us and we’ll answer all your questions. Simply have your insurance details at hand and we’ll verify your coverage.

We’re a fully licensed, Joint Commission-accredited, drug and alcohol treatment center located in Los Angeles. We offer a full continuum of care to individuals from all across the country. Call us today at 818.452.1676 to learn more about how we can assist you or your loved one.