Most insurance plans offer some form of outpatient treatment for alcohol use disorder. The individual’s insurance policy may not cover the entire cost of outpatient treatment, but it will cover at least some of the costs.
This is because the Patient Protection and Affordable Care Act (often referred to as Obamacare or just the Affordable Care Act), passed in 2010, made stipulations that insurers must provide essential health benefits as part of their overall service packages. The term essential health benefits is based on the definition from the National Academy of Medicine that designates the services as including mental health treatment, behavioral health treatment, and treatment for substance use disorders.
The Affordable Care Act (ACA) also extended the policies provided by the Mental Health Parity and Addiction Equity Act that required insurers to provide the same level of benefits for mental and behavioral healthcare treatment that they do for other primary health care services. This means that under the Affordable Care Act, both private and group insurance companies need to provide these benefits, and the level of coverage provided for the treatment of substance use disorders, such as alcohol use disorder, should be equivalent to the level of treatment provided for other primary health care issues. Thus, most insurance companies should cover at least some of the cost of outpatient treatment for alcohol use disorder.
Types of Outpatient Treatment Services That May Be Covered
The ACA was enacted to ensure that individuals would be provided with sound standard healthcare policies by insurers and that individuals who had pre-existing conditions (health conditions that were present before the person signed up for the policy) would not exclude someone from coverage. Thus, even though an individual may have been developing an alcohol use disorder for years before signing up with an insurance company for health insurance, they cannot be denied benefits.
This means that most insurance companies will provide some coverage for outpatient treatments, including:
- Withdrawal management or medical detox programs: This includes outpatient withdrawal management programs that require the use of medications to control withdrawal symptoms.
- Other medications used in the treatment of alcohol use disorder: Typically, insurance will provide coverage for medications that have research evidence showing they can be used for alcohol use disorder. Medications that are prescribed by a physician but not specifically designed to treat issues with alcohol use disorder may not be covered.
- Outpatient therapy: This is typically covered to some extent. Some therapies, such as rapid detox or therapies that are not directly associated with treating alcohol use disorder, such as acupuncture, may not be covered.
Again, insurance companies generally cover treatments that have empirical research evidence to support their specific use in treating an alcohol use disorder. Medications or other treatments that do not have documented empirically based research evidence to support their use for a specific issue in the treatment of alcohol use disorder will often not be covered, even if a physician prescribes a medication or recommends a specific treatment. Insurance companies are often able to provide lists of treatments and medications that are covered as well as a list of those that are not covered in these instances.
Most insurance companies require some form of copay for treatment services directed at alcohol use disorders. In addition, some policies may have deductibles or certain amounts that individuals must pay out of pocket prior to getting coverage for services. Once the deductibles are reached, then the insurance policy begins to cover services and provide benefits. Individuals should check with a customer service representative from their insurance company regarding their financial responsibility for different forms of outpatient treatment for alcohol use disorder.
Situations That Determine Coverage
Numerous situations or factors can determine the amount of coverage that an individual will receive for outpatient treatment. Some of the main factors that are considered by insurance companies regarding paying for treatment include:
- Medical necessity: The notion of medical necessity refers to the idea that the treatment provides the most efficient and practical form of care for the condition in question – in this case, for alcohol use disorder.
- Referral source: When physicians refer an individual to outpatient treatment for substance use disorder, insurance companies may be more likely to approve coverage if there is any question regarding whether the individual should receive coverage for the treatment.
- Research evidence: As mentioned, research evidence regarding the effectiveness of the treatment is important to insurance companies. Insurance companies more readily approve forms of treatment that have empirically validated evidence (research evidence) to support their use in treating alcohol use disorders. This includes different forms of behavioral therapy and medications.
- Policy type: The type of insurance policy one has will obviously have an effect on the extent of coverage for outpatient treatment.
Anyone who has insurance but is not sure of how much coverage is allowed for outpatient care can simply contact a customer service representative at their insurance company, and that individual should be able to provide them with all the information they need. An individual can also discuss treatment with an outpatient therapist, physician, or other treatment provider, and these professionals will often be able to determine the extent of insurance coverage the person has that can be applied to outpatient treatment. One can also visit their insurance company’s website and view the company’s policies and coverage practices.
Anyone does not have insurance but wishes to get treatment for alcohol use disorder can visit the Affordable Care Act website in order to find out what type of insurance programs they qualify for. Those who have a little or no income may be able to apply for Medicaid. Medicaid coverage includes treatment for substance use disorders, including alcohol use disorders; however, not all treatment providers accept Medicaid. One can visit the treatment locator tool at the Substance Abuse and Mental Health Services (SAMHSA) site to find treatment providers in their area that accept Medicaid or others form of insurance.