What You Didn’t Know About Insurance and Rehab

Making the choice to get treatment can be intimidating enough, no one needs the added stress of trying to figure out how to pay for it. Getting good treatment is not cheap but it doesn’t have to cost you as much as you think it does.

There are many insurance companies both private and public that have coverage for substance abuse treatment. However, just like with anything else, the amount of coverage varies. Your policy might have a maximum dollar amount or restrictions on what type of treatment is covered. The only way to know exactly what you are covered for is to call your insurance company, or verify your insurance by filling out the form below.

What is the Mental Health Parity and Addiction Equity Act (MHPAEA)?

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 is a law that states that health group health plans and health insurers provide the same level of benefits for mental and/or substance use treatment and services that is required for medical/surgical care.

MHPAEA recognizes that mental health and substance abuse treatment are a vital part of an individual’s wellbeing. The Affordable Care Act helps ensure that qualified healthcare plans offered coverage for many behavioral health treatments and services.

The MHPAEA offers the opportunity for effective substance abuse treatment that is completely or partially covered by health insurance companies. Drug and alcohol addictions are considered a disease and often have co-occurring disorders like PTSD, severe depression disorders, and other anxiety and mood disorders that influence the severity and susceptibility.

It is your right to have quality care when treating substance abuse and co-occurring disorders.

Does MHPAEA apply to those with Medicaid and CHIP? The Mental Health and Addiction Parity Rule

Since 2008 the MHPAEA has been been amended and updated. Where the previous final regulations of the MHPAEA apply to commercial market health insurance plans and insurance providers and not Medicaid and). The new proposed regulation aims to apply these changes to the Children’s Health Program (CHIP) and Medicaid healthcare plans. This gives those who have mental health or substance abuse disorders a greater chance to be able to receive the treatment they need in a fair manner.

Finalized Amendments to MHPAEA Rule
All knowledge is worth knowing when making your mind up about inpatient coverage and outpatient coverage. Staying up to date on the MHPAEA Rule will ensure that you will get the most effective treatment that is long-lasting and life changing:

  • Assuring treatment such as residential or intensive outpatient settings are covered fairly as well as all other types of intermediate levels of care.
  • Promote clarity and address the transparency that is to be required of health plans which include disclosure rights of plan participants. This aims to help ensure compliance with the law.
  • Define the consistency that applies to all plan standards, including geographic confines, facility-type limits, and network sufficiency.
  • It will take out the exception to the existing parity rule, which has been determined as confusing, unneeded, and prone to abuse.

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How Does the MHPAEA Work to Your Advantage?

MHPAEA will make sure that the health insurance provider’s coverage plans cover mental health and substance abuse disorders in the same way that they would cover medical and surgical conditions. The requirements would apply to the following:

  • Copays, coinsurance, and out-of-pocket maximums.
  • Restrictions on inpatient days or outpatient visits that are covered.
  • The utilization of care management tools.
  • Coverage regarding out-of-network providers.
  • Criteria for medical necessity during detox, therapy and continued care.

The MHPAEA doesn’t actually require plans to offer coverage for mental illness or substance abuse disorders, but it assures that if they do, they must offer the coverage with the same equality and consistency with which they offer coverage for medical/surgical health conditions.

This will ensure that those who are beneficiaries of insurance companies that do offer coverage for mental illness and substance abuse will be able to get the treatment they need without having so many obstacles, just as they would if they were physically sick. After all, substance abuse and mental illness do risk the overall physical health of a person who is struggling.

Affordable Care Act Extension of MHPAEA Requirements

The Affordable Care Act extends the reach of MHPAEA’s requirements. In 2014, all small group and individual market plans that were created after March 23, 2010, will have to comply with federal parity requirements. All qualified health plans that are offered through the Health Insurance Marketplace in every state will have to include coverage for mental and/or substance abuse disorders. The Affordable Care Act adds mental and/or substance abuse disorders to the top 10 categories of Essential Health Benefits. This act also influences the coverage complies with MHPAEA’s requirements.

Small health group plans are defined as employment-based plans that include no more than 50 employees. Small group plans created before March 23, 2010, will be exempt, and not subject to the Essential Health Benefits requirements or MHPAEA.

Large group plans are employment-based plans that include 51 or more employees. Individual plans are plans that are purchased individually direct from an insurance company, and aren’t employment-based.

The Department of Health and Human Services (HHS) has recent information  that explains how the federal parity requirements will apply to the Medicaid managed-care organizations, Children’s Health Insurance Program (CHIP),  and in states that make expand Medicaid, to Alternative Benefit Plans.

You can find the link here:  Guidance: Centers for Medicare & Medicaid Services (CMS) Letter to State Medicaid Directors – 2013 (PDF | 157 KB)

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