Is Drug Addiction a Pre-Existing Condition?

“Will my insurance cover addiction rehab?”

This is a question many people ask themselves when considering drug & alcohol addiction treatment. Understanding your insurance, what policy you have, if taking disability leave is an option, and if attending drug rehab will be covered can be highly confusing.

This situation can be a serious obstacle to receiving successful treatment.

So, let’s explore pre-existing conditions, insurance coverage for them, and whether or not drug addiction is one of them. To start, we have to understand what a pre-existing condition is.

A pre-existing condition is any health condition that a person has before getting health insurance coverage. Some examples include pregnancy, cancer, and diabetes. Insurance companies can't deny you coverage or raise the costs because of this condition. 

Pre-Existing Mental Health and Substance Use Disorder Protections

Just as any health insurance provider can't deny coverage for those with diabetes or cancer, they can't deny coverage for people with substance use disorder (SUD). Most insurance plans also cannot put any spending limits or caps on mental health services or addiction treatment.

There are also certain protections for drug treatment and mental health services. These protections ensure that if there are any limits applied to mental health and drug treatment services, they can't be any more strict than medical or surgical limits. 

The protections include: 

• Financial: Deductibles, copayments, and out-of-pocket costs

• Treatment: Number of days or visits covered by the insurance

• Care management: Requirements to get approved for treatment before getting it

Health insurance also cannot place a dollar limit amount on the “10 essential health benefits,” which include: 

• Ambulatory patient services 

• Emergency room visits 

• Hospitalizations 

• Maternity care 

• Mental health services and addiction treatment 

• Prescription drugs 

• Rehabilitation services and devices 

• Laboratory services 

• Preventative services 

• Pediatric services 

The Role of The Affordable Care Act

The Affordable Care Act (ACA) is a law put into place in 2010 by former President Barack Obama. This act was put in place to ensure healthcare coverage for uninsured Americans. The ACA was also created to create a better healthcare system in the United States for all, by expanding the services to make healthcare more inclusive and affordable. 

Since the ACA, mental health disorders and SUD are now considered pre-existing conditions. Before this, insurance companies would frequently deny individuals health insurance coverage because of these conditions. This meant individuals with these legitimate conditions might have had high copayments or out-of-pocket expenses. These costs make it difficult or even impossible for many people to receive treatment. 

How to Qualify for the Affordable Care Act 

To qualify for the benefits of the ACA, there are a few requirements you must meet, including:

• You must be currently living in the United States

• You must be a citizen or a legal resident of the United States

• You are not currently incarcerated

• Your income is no more than 500% of the Federal Poverty Level (FPL)

When looking into coverage with the ACA, the best place to start is to discuss costs with the rehab facility you have chosen. Unfortunately, a lot of these plans have high deductibles, and if this is the case, you may have some fees to pay before coverage with the ACA kicks in. Luckily, you don't have to worry about being denied coverage because of your SUD.

Through the confusion, you can count on any of the clinical staff members at The Edge to help you figure out exactly how much coverage you can receive with your individual plan. 

Circumstances That Can Effect Coverage 

There are a few events that can affect the level of coverage from the ACA insurance plans. For example, the type of insurance plan you have, whether through private insurance or a government-funded program, certainly affects your coverage. Depending on the type of insurance, you might have to receive a referral from a primary care doctor to start treatment. 

Also, the ACA provides for pre-existing conditions like addiction to legal addictive substances such as prescription opioids and alcohol but addictions to illicit substances may disqualify you from coverage. This may be a good time to check with the rehab facility you have chosen and see where exactly you stand on qualifying.

Medicare and Medicaid 

Besides the Affordable Care Act, Medicare and Medicaid are also options to help pay for drug treatment. However, they both work a bit differently, and pre-existing conditions can be factors in different ways.

For example, with Medicaid, coverage varies by state. This means each state is allowed to choose how much gets covered for different services such as counseling, medications, and support groups. 

On the other hand, Medicare provides its services broken into different categories, hospital, medical, and prescriptions. 

• Medicare A: This option covers the inpatient costs of a hospital stay

• Medicare B: This option provides coverage for outpatient services such as therapy visits and any lab tests that you may need

• Medicare D: Coverage for prescription drugs is provided with this option

Cross-check your options for Medicare and Medicaid against your treatment center options to ensure you as an individual are covered and whether the services you need have coverage.

The Edge Treatment Center Works with You to Find Addiction Treatment

Here at The Edge Treatment Center, we understand how confusing insurance can be for treatment. It’s why we help with any concerns or questions you may have. We emphasize the importance of community and make it known that you are never alone during this process.

Attending treatment is hard for so many different reasons, not the least of which is cost, and we want to provide as much information as possible to make it easier.

Want to learn more? Contact The Edge Treatment Center today!