Many Americans would likely agree that the most complex aspect of health insurance is getting claims paid, but the interaction of insurance policies and state and federal laws is equally complicated. When insurance companies draft policies, they must observe relevant state and federal laws. The resulting document, the Summary Plan Description (SPD), should accurately reflect the law as well as the insurance company’s contractual promises to cover certain services. In this way, at the insured’s level, the SPD is a critical document to be acquainted with as insurance claims processors rely largely on this document to pay or decline to pay for services. Individuals who currently have employment-based insurance, other private insurance, Medicare, or Medi-Cal (California’s Medicaid program for qualifying children and low-income persons) will have an SPD (or individuals may request a copy directly from the insurance carrier).
The ACA and California Plans
In March 2010, the Obama administration changed the landscape of the US healthcare system with the passage of the Affordable Care Act (ACA). One of the policy components of the ACA was a federal commitment to expand coverage for substance abuse treatment services. The government achieved this by designating substance abuse treatment as an “essential health benefit,” which means that all ACA plans must provide coverage in this area.
Although coverage for substance abuse treatment has been expanded, insured persons are still advised to review the SPD and speak directly with the insurance carrier regarding the allowances and limits of covered services. The ACA does not cover each and every drug recovery service available in California or elsewhere.
The ACA created a “Marketplace” in which individuals can shop for private plans that meet all the requirements of the ACA. In turn, states, including California, created their own online marketplaces. The ease of access Californians now have to finding insurance is a way of helping ensure greater coverage across the state. In terms of coverage for substance abuse treatment, Californians will find that the healthcare plans from the Marketplace are likely to be superior to the private health insurance plays of yesteryear.
As South California Public Radio reports, California Health & Human Services found that prior to the ACA approximately 33 percent of Californians who bought a private health insurance plan did not receive any coverage for substance abuse treatment. Of those insurance plans that did cover substance abuse treatment, the services were more restricted and limited compared to the treatment of other diseases (i.e., the coverage lacked parity with the coverage of other health conditions).
As California has the highest state population in the US (37,253,956 in 2010), the expansion of treatment services and improved access to health insurance likely help to close the nationwide gap between individuals in need of recovery and those who actually receive treatment services. Now that the ACA is in effect, plans purchased on the California Covered Marketplace cover the following substance abuse treatment services:
- Inpatient services
- Inpatient detox at a residential facility
- Outpatient care (day treatment)
- Intensive outpatient care
- Individual counseling
- Group counseling
- Medical help for withdrawal symptoms
The expansion of coverage may provide more services for potentially lower costs, but it is important to bear in mind that insured individuals will still be responsible for paying premiums and any deductibles, copays, or cost-sharing associated with their specific health insurance plan.
Marketplace plans in California (and the rest of the country) follow a tiered system. In terms of premiums, the least expensive plans are those in the Bronze category, and the most expensive are in the Platinum group. Californians with any ACA plans, Bronze to Platinum, can expect to have coverage for certain substance abuse treatment services. However, those Californians who are Bronze level will likely have higher deductibles and copays compared to those who are insured under a Platinum-level plan. Having an understanding of one’s SPD will help to determine how much treatment will actually cost (i.e., the out-of-pocket costs after insurance). There is always the option to contact the insurance provider as well.
Individuals who are readying themselves for treatment will have the option to speak with a financial coordinator on staff at the chosen rehab center to discuss any concerns about a gap between covered and non-covered services or the costs associated with cost-sharing. Some treatment centers may provide a payment plan or other options for the out-of-pocket portion of treatment, if any. It is important not be discouraged by insurance plans that do not provide 100 percent of the coverage needed. There are many payment options available to make treatment financially feasible.
To provide insight into where Californians get coverage, a survey called the 2013 Health Insurance Coverage of the Total Population provides the following information:
- 15 percent of Californians have no insurance
- 19 percent receive Medi-Cal/Medicaid
- 45 percent have employment-based plans
- 7 percent have private insurance (other than employment-based insurance)
- 12 percent have Medicare
- 2 percent have public insurance other than Medi-Cal/Medicaid
Based on these statistics, the ACA can potentially help 55 percent of the population of California (includes Medicare recipients). A main goal of the ACA, as well as other federal laws related to coverage expansion and parity, is to help eliminate barriers to entry both to substance abuse programs as well as general health care visits. Being in good health reduces the risk of substance abuse, so in this way, the ACA not only addresses substance abuse but can also help to prevent it (i.e., good health is a protective factor against developing substance abuse).
How to Use the California Marketplace
Covered California is the official website for health insurance plans on sale in the California marketplace. Individuals who are uninsured can purchase brand-name health insurance plans in the Marketplace. Special rules may apply to individuals who have access to health insurance through their employer, a marketplace “navigator” may be contacted for further information.
Before the ACA, individuals only had the option of purchasing private health insurance on the open market. Individuals still have that option, but plans in the Covered California marketplace fulfill all the guarantees of the ACA regarding substance abuse treatment. An added benefit of marketplace plans is that some individuals may qualify for a government subsidy of their premium payments. In addition, some eligible people will receive a tax credit for part of their out-of-pocket premium costs. Plans that are purchased on the private market are not eligible for government assistance.
In California, the open enrollment period runs from November 1, 2015 through January 31, 2016. Special enrollment is available for certain life events (i.e., qualifying events) such as getting married, having a child, or moving. Special enrollment often has its own time limit (such as 60-90 days). For this reason, uninsured individual who experience a qualifying event are best advised to seek coverage as soon as possible after the event.
Applications can begin online, or individuals may call a navigator at (800) 300-1506 at any point in the process. During the application process, individuals will be able to review different plans, basic information about coverage, and premium costs. According to information from Covered California for 2014, the following large and regional private plans are a sample of the plans that were available on the marketplace and guaranteed to meet all the requirements of state and federal law:
- Blue Shield of California
- Sharp Health Plan
- Kaiser Permanente
- Valley Health Plan
- Health Net
- Molina Health Care
- Anthem Blue Cross of California
- L.A. Care Health Plan
- Chinese Community Health Plan
- Western Health Advantage
In order to complete an application, a Californian will need income information, identification, proof of US citizenship or an immigration document that shows lawful presence in the US, a Social Security number, and zip code. Once a plan is selected and approved, individuals may pay their first month’s premium online or wait for a bill to arrive in the mail. Marketplace plans are available for individuals and families.
What Is Medi-Cal?
Certain qualifying individuals may apply for Medi-Cal (California state Medicaid) through the marketplace. Medi-Cal enrollment is open 365 days a year. Medi-Cal programs can cover low-income adults, persons with disabilities, seniors, families with children, foster youth (maximum age is 26), and pregnant women.
Medi-Cal plans are either free or low-cost. Medi-Cal provides all of the same essential health benefits of private Covered California plans. Once a person or family is found to be eligible for Medi-Cal, the next step is to choose an insurance provider.
Persons who have Medi-Cal can avail themselves of a separate program specifically for substance abuse treatment that is called D-M-C (Drug Medi-Cal). If a physician determines that a person with Medi-Cal requires substance abuse treatment, that person can be referred to any one of more than 1,400 Medi-Cal certified recovery facilities throughout California. Medi-Cal services in these recovery programs include inpatient detox, inpatient treatment, outpatient counseling, and methadone maintenance.
People insured under Medi-Cal are eligible for six months of drug recovery treatment. If the recovering person requires additional treatment time, a counselor or physician will work with Medi-Cal to set up treatment in six-month increments for as long as needed.