It’s the new year … do you understand the Affordable Care Act? Here is the short version: you are required by law to have health insurance. That doesn’t mean you will be thrown in jail if you don’t sing-up. However, if you don’t purchase a plan, you will face a harsher fine in 2016. For some folks, this is going to mean twice as much, as last year.
Those without health insurance were charged $325 or 2 percent of their household incomes–whichever was higher–in 2015. That penalty will jump to $695 per adult, or 2.5 percent of their income, in 2016, according to the government.
This brings me to my insurance “hack” – understand the ten essential benefits under the ACA.
That sounds kinda boring. Yes, but finding out that addiction, alcoholism and mental health services are covered, is kinda fun. The covered services include behavioral health treatment, counseling, and psychotherapy
Here is the not so fun part (referenced by Healthline):
Even with the Affordable Care Act (ACA), which mandated that certain mental health services be covered, many people don’t receive the care they need because there aren’t enough therapists to go around.
That’s despite the fact that 20 percent of children and 18.5 percent of adults have, or have had at some point, a seriously debilitating mental disorder, according to the National Institute of Mental Health (NIMH).
That means that millions of Americans with mental health issues — are receiving whatever care they do get from general practitioners.
A number of organizations have predicted a serious shortage of both doctors and nurses. Now, it appears the therapy field is experiencing the same phenomenon.
What’s Causing the Shortage?
It’s a simple case of supply and demand. The ACA dramatically increased the number of insured Americans, and the types of things health insurance policies must cover.
ACA also classified mental health professions as primary care professionals. This means patients can see a therapist without prior approval from their regular doctor.
So, does this mean mental health services are easier to come by in the United States? Not really. Michele Paiva, a licensed psychotherapist practicing in Pennsylvania, said the ACA has opened some doors to care, but that doesn’t mean the treatments are affordable.
“It is true more people are insured, but depending on the coverage that they have, they may or may not be able to afford therapy still, and the insurance is still dictating the therapy, as opposed to the therapist telling the insurance what the patient or client needs,” she told Healthline. “I find that my therapy clients are looking toward the self-pay option more and more. More now than ever before, therapists are not participating in insurance for this very reason.”
Besides dictating care, interactions with insurance agencies are often riddled with paperwork and other issues. Most therapists are self-employed, so taking time to get paid from insurance companies pulls them away from their clients..”
In fact, half of psychiatrists — who, unlike most psychologists, have a medical degree and can prescribe medication — don’t accept health insurance, according to a study in the journal JAMA Psychiatry.
More Barriers Between Professionals and Patients
Besides insurance, there are a lot of other things standing in the way of getting people the help they need. Part of the problem is that some insurance companies have stopped adding clinicians to their networks.
There’s also the fact that college tuition has skyrocketed in recent years. There’s no incentive to spend large amounts of money preparing for a career that may not pay enough.
“The rising cost of education is a barrier for many who are attracted to this profession. Money continues to be a factor throughout one’s career,” said Robinson, a licensed clinical professional counselor herself. “Mental health professionals often engage in years of unpaid clinical internships and residencies in pursuit of independent licensure.”
Before getting into the profession, Coleman recommends having a realistic and workable plan laid out beforehand. This includes knowing how long the process takes, including becoming established, marketing, and handling the business side.
What rights do you have?
Under the ACA, coverage for addiction treatment must be as complete as it is for any other medical procedure. Some of the things you can get with these insurance plans include:
- Addiction evaluation
- Brief intervention
- Medication for addiction treatment
- Visits to the clinic
- Drug and Alcohol appointments
- Home health visits
- Counseling for the family
- Anti-craving medication
ACA health insurance plans also helps with inpatient services like medical drug detox programs. Some states run their own marketplace sites for Health Insurance (these are separate from Healthcare.gov).
Before you pick a marketplace plan – ask:
1. What mental health and substance use disorder services are covered and what is the amount of copays and coinsurance?
2. Are your healthcare providers included in the network as preferred providers?
3. Are the medications, you take (or might need in the future) covered?
Don’t let confusing laws or doctor shortages fool you.
I can help. Don’t allow confusing laws dissuade you. Many addiction treatment centers accept ACA and similar Marketplace plans. An addicted person can buy one of these plans. If you missed one of the deadlines, there are special exceptions that you might be eligible for. Don’t let healthcare shortages prevent you from getting the best treatment. Many of the top treatment centers have empty beds. If you have partnerships (like we do) you know where to look.
I recently started an Instagram account. If you enjoy the platform …. I follow back.
800 Recovery Hub Blog 
It’s very interesting indeed to hear about the ACA and how it operates in the US. Although there is a National Health Service in the UK, I also have private healthcare insurance. But the only thing I ever need to claim for is mental health disorders which they always say are not covered because the condition is chronic or the amount of therapy I need exceeds the annual amount payable in the plan. I’ve never tried to claim for in-patient drug treatment and hope I never have to but it is incredibly frustrating that my health care insurance never covers what I need. http://bit.ly/1ER5cLY
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I truly appreciate you taking time to share your insightful experience. I know very little about the government provided insurance in the UK. It sounds like it works (for the most part). However, you have made me curious to know if they pay for in-patient rehab. It is so very expensive here in the US.
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One of the challenges of ACA – now you HAVE insurance, and let’s say you found a provider who is taking new patients AND accepts your plan (and many providers don’t accept insurance – or if they do, often don’t take “marketplace plans”) – you still likely have a pretty significant deductible to pay before coverage kicks in. And that $2k or $5 or HIGHER deductible might be the wall that’s too high to climb to get what you need.
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Very true Katie. The one exception is for people who are in their twenties. If you’re young you can get an affordable premium plan.
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I’m so happy to see you discuss ACA. As a tax preparer and Marketplace user any voice who can add positivity and greater understanding to this system gets 100 random bonus points in life. Thank you! Lori
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Thank you for this post. I’m always looking for information on ACA and how it’s impacting other people. It’s been a Godsend for me but I’ve heard so many people say how it’s hurt them and I found myself wondering how it helped me so much and hurt others? I’m glad to see information about ACA related to addiction treatment, as my eyes were opened to the reality a year ago.
A life long friend who has been battling multiple prescription medication addictions for years either nearly accidentally over dosed, or tried to commit suicide, even he wasn’t sure. After they pumped his stomach and medically stabilized him, he asked to go to rehab. I was over joyed. We have an excellent facility in the area and he was transferred there the next morning. He called me the following night sobbing that it was only a 72 hour psych hold because that’s all insurance would pay for.
It’s been a year long battle for him. He did well for a few weeks after but went back to using.
His family turned their backs on him and he put me as his only “person” to contact on all his medical forms. In October he did try to commit suicide with the pills, they again pumped his stomach and had to use charcoal. I was called. He survived but had aspirated some of the stuff into his lungs and had to be admitted to Pulmonary ICU.
As luck would have it the attending doctor was my pulmonologist.
He asked if I thought my friend had the kind of fight in him I had when I fought septic shock and just needed someone to prove it to HIM. I told him there was a reason God put me in that ICU room, with the doctor that fought the hardest to save my life, standing with me.
I still don’t know what strings he pulled but a week later my friend was in a full 28 day rehab, and came out with a TEAM of people helping him fight his addiction. Last Monday I got to go to a friends and family celebration for his 90th clean day!
I do know that our doc used little known measures in ACA to help grease some wheels. I don’t understand them, so I can’t explain them, and I don’t know how many doctors A) know about them and B) take time to do the leg work to help patients. I sometimes get discouraged with the medical community, they don’t seem to want to help that much. Doctors like my pulmonologist seem few and far between. Finding resources to help others is always a plus in my book. Thank you for this post. I am bookmarking it and passing it on to my friend and others that will find this entire blog helpful!
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A fascinating insight in to American healthcare and insurance.
Even though we have the NHS here in the UK the mental health care available is not gold standard. There are very long waiting lists for counselling, behavioural therapy etc. People who should receive a hospital admission remain treated as an outpatient. There are not enough specialists or specialised wards to meet demand, therefore the general go-to treatment is medication via your GP. Patients remain on fluoxetine, duloxetine, citalopram, or whatever their tonic of choice is, for years and years -whilst the actual root cause often remains untreated.
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Thanks for sharing your unique insight, Rebecca. We can learn much from the NHS system. Do they have any drug rehabs that are covered by insurance? I am also wondering if your country has a “sober living” option? In the US, many folks who can’t afford continual care give that a try. It’s not the best option, because there is no medical treatment, just a “fellowship” of people living together with a common goal. In any case, thanks for checking in. I am traveling across the country right now (in an RV) … just my husband, our 8 year old and I. What I treat to read your comment this morning. Cheers. (I think that’s the common term there)
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Well done. We need more of these explanations to better understand what the ACA is all about, how it impacts us, and what it covers.
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Thank you so much for sharing and giving everyone so much hope for recovery. I’m a new blogger here on WordPress and will be writing a ton about my eating disorder recovery and my depression. Please follow my journey, thanks everyone https://vegtablessite.wordpress.com/2016/03/30/an-open-letter-to-my-eating-disorder/
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