Does Obamacare Cover Rehab?

Obamacare and Rehab: Key Takeaways

• Does insurance cover rehab? In most cases, yes. Under the Affordable Care Act, substance use disorder treatment is one of the 10 essential health benefits that marketplace and most plans must cover.
• Coverage can’t be denied for a pre-existing substance use disorder, and marketplace plans can’t put yearly or lifetime dollar limits on addiction treatment.
• Coverage doesn’t mean free: most plans use cost-sharing (deductibles, copays, coinsurance), so you typically pay part of the cost, often far less than the sticker price.
• The fastest way to know your benefits is a free, confidential verification, which takes only a few minutes.

One of the biggest myths about addiction treatment is that no one can afford it. The reality, thanks to the Affordable Care Act (ACA, sometimes called Obamacare), is that coverage for addiction treatment is now a legal requirement for most health plans. 

So does insurance cover rehab? In most cases, yes. Here’s exactly what the ACA requires, what affects your out-of-pocket cost, and how to confirm your coverage quickly.

Is Rehab Covered?

Rehab is covered by the Affordable Care Act (ACA). According to HealthCare.gov, substance use disorder services are one of the 10 essential health benefits that marketplace plans must cover. This means that all health insurance plans that meet the Affordable Care Act’s guidelines for minimal essential coverage include coverage for substance abuse treatment.

However, it should be noted that most of these plans cover these treatments as part of a cost-sharing plan where the insured needs to pay some of the costs associated with treatment, whether it be inpatient rehab or outpatient addiction treatment. Some preventive services are covered in full, but rehab programs usually involve some out-of-pocket cost.

Each plan available on the marketplace offers different coverage availability and rates, so it is important to understand exactly what you are signing up for to make sure you choose the right plan for your specific needs. You want to find the plan that provides the most coverage for the services and medications you need.

Many of the health insurance plans available on the health insurance marketplaces have a high deductible. This means that you will have to pay the deductible first before coverage is provided under the plan. Before enrolling in a particular addiction treatment program, clarify exactly what your out-of-pocket costs will be. Generally, a representative for the program can serve as a liaison with your insurance company, helping you to determine your exact level of coverage.

What the ACA Requires Insurers to Cover

The ACA sets clear protections for anyone seeking addiction or mental health treatment:

• Behavioral health treatment, inpatient mental/behavioral health services, and substance use disorder treatment must be covered
• Insurers cannot charge more or deny coverage for a pre-existing condition, including a substance use disorder
• Marketplace plans cannot impose yearly or lifetime dollar limits on substance use disorder services
• Any limits on care must match regular medical coverage and can’t single out addiction treatment

Factors That Affect Coverage

There are some factors that may impact the type of coverage that is covered by Affordable Care Act health insurance plans. Prior attempts at rehab should not make any difference from an insurance standpoint; however, depending upon the type of insurance plan (HMO or PPO), you may be required to get a referral from your primary care doctor to receive treatment for substance use disorders.

Additionally, not all types of addictions are covered by health insurance. Most substances that are known to be addictive are covered, including opioids, alcohol, and various recreational drugs. However, the medical community’s understanding of addiction constantly evolves. Some other addictions, such as certain behavioral addictions, may not be covered. It is worth checking with your primary care physician, specific treatment center, and health insurance provider to determine what is covered.

Existing Treatment Limitations under the Affordable Care Act

While Obamacare does not specifically clarify a limit on the number of treatment days or sessions, there is a clear preference for individuals to try outpatient rehab first before inpatient care is recommended. According to Health Affairs, the Affordable Care Act prefers outpatient treatment that is integrated with many health disciplines. This means that health insurance companies want individuals to try less expensive outpatient options first before enrolling in inpatient care, which is generally more expensive.

Additionally, the ACA ensures treatment, not necessarily the proximity of the treatment to the policyholder’s home or the expediency of that treatment. Sometimes, you may need to travel for care based on your insurance coverage or wait for an appointment at a covered facility.

How a Person Can Determine Exact Coverage for Rehab Programs

Since your level of coverage for rehab services and how much you’ll pay in out-of-pocket costs vary widely by your specific health insurance coverage, it’s important to find out what’s covered. Here are some ways you can find out the specifics of your exact coverage:

• Call your health insurance company using the number found on the back of your insurance card.
• Check online at your health insurance company’s website or on HealthCare.gov.
• Ask your primary care doctor for in-network referrals for treatment programs.
• Contact treatment centers directly to see which insurance plans they accept. Once you’ve chosen a prospective treatment center, ask them to verify your coverage specifics.

According to the Archives of Physical Medicine and Rehabilitation, some medical specialties may face more demand than the available doctors and specialists can realistically treat. This may mean longer wait times for patients. To avoid long delays in treatment, find the names and contact information for a few different doctors, specialists, or rehab centers that are covered by your specific insurance policy.

Verify Your Insurance Benefits Today

It’s easy to see if your healthcare insurance, including Obamacare, will help you pay for addiction treatment costs: Just fill out the form below.

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