What the Affordable Care Act Means for Substance Abuse Treatment

Affordable Care Act (ACA) Overview

The Patient Protection and Affordable Care Act (PPACA or ACA, also called Obamacare) is a federal healthcare law passed in 2010. It ensures Americans have access to health insurance regardless of their income, employment status, or health status (any pre-existing conditions). 

The ACA “sponsors” private insurance plans through the Health Insurance Marketplace. Customers have access to affordable healthcare coverage. They might also be eligible for tax credits that make coverage even more economical.

ACA coverage includes many essential health benefits, including addiction treatment and mental health support.

Health care providers accept Marketplace insurance the same way they do any other plan.

Under the ACA, addiction is no longer considered a pre-existing condition. In the past, insurance companies could deny coverage based on how they classified addiction. 

Now, health insurance has to cover mental and behavioral health treatment like any other illness or condition.

What Does the Affordable Care Act Cover for Substance Abuse Treatment?

The ACA offers essential health benefits “as complete” as coverage for other illnesses or medical procedures. 

Under the ACA, treatment coverage, in part or in full, for addiction includes:

• Evaluation
• Intervention
• Medication
• Clinic visits
• Alcohol and drug testing
• Home health visits
• Family counseling
• Anti-craving/relapse prevention medication
• Medical detox programs
• Inpatient treatment
• Mental health support
• Behavioral health treatment

Under the ACA, addiction is treated like any other disease or medical condition. 

In the past, people with substance abuse issues often “hit rock bottom” before receiving insurance coverage for treatment.

The updated approach under the ACA means more access to medical screenings, education, and community prevention.

Despite the coverage for addiction-related services, you’ll still have out-of-pocket costs for treatment.

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Who is Eligible for ACA Coverage?

Anyone can purchase insurance through the Marketplace.

However, to qualify for tax credits, customers must have an income between the federal poverty level (FPL) and four times the FPL.

The exact income limit varies based on family size. 

Some plans offer cost-sharing support for people living 2.5 times below the FPL. Cost-sharing support reduces premiums, co-payments, deductibles, and other out-of-pocket expenses.

Many states operate Health Insurance Marketplace platforms separate from Healthcare.gov. 

Differences between state and federal medical plans are based on each state’s Medicare and Medicaid coverage.

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Additional Mental Health Protection

In addition to the protections the ACA offers, other laws protect people with mental health and substance use issues.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equality Act of 2008 (MHPAEA) is another federal law that protects health insurance customers. 

Initially, this law applied to group health coverage. Under the ACA, MHPAEA was amended to apply to individual coverage, Marketplace plans, and Medicaid programs.

Under these laws, any limits applied to mental health and substance abuse coverage can’t be more restrictive than those applied to other services. 

Protections include:

Financial

• Deductibles
• Copays
• Coinsurance
• Out-of-pocket limits

Treatment

• Number of days
• Number of visits covered

Care Management

• Advanced authorization requirements

What the ACA Doesn’t Cover

Despite the improvements the ACA has provided, the law doesn’t guarantee quality addiction treatment services for everyone.

Addiction treatment advocates point out that many ACA-covered treatment programs are not evidence-based. 

Medical and scientific communities advocate for a combination of behavioral, psychological, and pharmacological therapies for addiction. The ACA offers coverage for these types of programs, as well as alternative treatment options.

Some believe this is confusing and/or misleading. They want the ACA to cover only evidence-based programs so there is no doubt they’ll receive effective treatment.

Even those critical of the ACA’s expansive coverage commend the program for helping remove the stigma around mental health issues and substance abuse.

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How to Apply for an ACA-Sponsored Plan

To apply for an ACA-sponsored plan, visit HealthCare.gov. You’ll be directed to your state’s insurance marketplace website. There, you can learn more about the medical and surgical services and addiction treatment programs options available to you. 

Plans, prices, subsidies, and programs vary by state. 

Contact the Marketplace Call Center or a local center to speak to a representative if you have questions. Or, you can apply in person.

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