Addiction Treatment and Your Health Coverage Addiction – How to Get Help

Addiction Treatment and Your Health Coverage – How to Get Help

Addiction was not truly considered a diagnosable and treatable mental illness by the U.S. medical community until about forty years ago. And while we no longer see an addict’s need to use as a failing in good judgment, stigmas still cloud the public image of people who need specialized substance abuse treatment to stop.
According to the 2012 National Survey on Drug Use and Health, over 21 million Americans struggled with a dependence on drugs or alcohol last year, but less than 2.5 million received treatment at a specialty facility. The report also points out that a full quarter of those that needed treatment did not receive it because they lacked health insurance.
While addiction affects nearly 24 million people over the age of 12, only 11.2% of those individuals receive treatment from a private facility (SAMHSA, 2009). It’s not uncommon for private recovery facilities to cost in the tens of thousands of dollars.
Fortunately, under the new healthcare laws, addiction treatment is deemed “an essential health benefit” that commercial health plans must cover. In fact, the number of patients seeking treatment for drug and alcohol problems could more than double over the next year as the rolling healthcare reform measures come into effect.
You can and should get cost-effective and valuable addiction treatment when it’s needed. Educating yourself on your health plan, your state’s laws, and the steps to get care make that an achievable goal.
Understanding Your Addiction Treatment Coverage
Addiction is legally defined as a diagnosable medical condition, but the stigma that accompanies drug or alcohol abuse has historically made it difficult to get care: families or individuals may be hesitant to push for their rights, and some health plans have financial incentives for denying treatment, so they may twist words around in a health policy in order to misrepresent what’s required of them.
Though insurance companies may not always advertise this fact, as of now, 43 U.S. states require commercial group health insurers to cover addiction treatment. If you or a loved one is in need of either detoxification or rehabilitation treatment, it’s critical to know how your insurance policy is worded and exactly what rights you’re entitled to as a policyholder.
Start by looking at your health plan. Wording in that policy should define a full continuum of addiction care, which, according to the National Alliance for Model State Drug Laws, includes “intervention, detoxification, inpatient rehabilitation, outpatient treatment, and intensive outpatient, family, and codependency treatment.”
Keep in mind that The Mental Health Parity and Addiction Equality Act of 2008 makes it illegal for insurance companies to discriminate against patients because of addiction. (The MHPAEA does not require your insurance to cover specific addiction disorders or treatments, but it does require that coverage for mental and substance abuse disorders be offered at parity with standard medical conditions.)
If you aren’t clear on your specific treatment options and rights, you should take two steps:
-Contact your insurance company to clarify the policy with them.
-Check the NAMSDL website to find your state’s lead agency for administering addiction treatment services: this differs by state, but that agency should be able to clarify the exact laws and policies.
Working with patient advocacy groups like NAMSDL or the Substance Abuse and Mental Health Services Administration (SAMHSA) can also be useful. SAMHSA is comprised of subject-matter experts that advise the Department of Health and Human Services, and as such they’re able to provide consumers with a wealth of information on their rights in regards to health care.
Another option is to contact a third party association, like Addiction Treatment Services, that can help you find a health insurer providing clear and affordable coverage for addiction treatment. Keep in mind that these third parties do not offer specialized options, discounts or services that cannot be found through each insurer directly.
Given the state laws regarding all commercial group health insurers, trying to navigate a difficult insurance situation while also struggling with addiction may sometimes be too much to handle: switching to a policy that does uphold those state laws could be easier than fighting with your current insurer. On the other hand, as will be explained later, there are ways to stand up to a reticent insurer, and it’s through that advocacy that the stigma associated with addiction treatment can and will change.
Know the Standard Coverage Levels in Your State
With the exception of Arizona, Georgia, Indiana, Iowa, Idaho, Oklahoma, and Wyoming, all states currently require commercial group health insurers to cover addiction treatment services as they would any other prescribed medical treatment. To find out more about the current laws regarding coverage of substance abuse treatment in your state, contact your state’s insurance commission or the National Alliance for Model State Drug Laws.
Most commercial group health care policies include provisions for detoxification treatments that require hospitalization or in-house care as well as out of house care. To give you an idea, many providers say coverage and reimbursement rates average out to 70-75% of total costs per patient.
Inpatient Care Costs and Coverage
Some health insurance policies cover 100% of inpatient costs for an unlimited number of days, though certain plans limit the number of days or require copayments. It is critical that policyholders understand their coverage plans regarding inpatient care, as some plans will expect patients to contribute approx. 10-50% copay. In this case, residential treatment can be overwhelmingly expensive. In a 2011 survey of over 44 private treatment providers nationwide, these average costs were reported:
– Medical detox: $1,707 per day
– 28-day residential treatment programs: $19,067
– 10-week intensive outpatient programs: $6,863
If you’re insurance policy does not currently cover the inpatient care that you or a loved one is in need of, discuss your financing options with both your doctor as well as the treatment facility you’ve been referred to. Because rehabilitation centers have extensive experience fighting for patients’ rights and negotiating with insurers, they’re often able advise you in securing fair coverage.
Outpatient Care Costs and Coverage
This all sounds very expensive remember that for the majority of the country’s 20 million patients struggling with substance abuse, treatment doesn’t require inpatient treatment. In one study of Californian claims for substance abuse treatments, for example, 27% of insured patients only needed between $1-100 worth of services, while 20% needed $1000-2,500 worth of care.
Rehabilitative care can overlap with detoxification — most policies include the 20-visit-per-year provision, as well as requiring copayments. Rehabilitative care encompasses counseling but does not usually include home residential care. (Some policies allow you to add a rider, at additional cost, for the latter type of treatment.) Outpatient care will usually include a blend of prescribed treatment medications that will help addicts reestablish and maintain their brain chemistry and function as well as ongoing behavioral therapy sessions.
Obviously, treatment approaches and their costs vary as widely as the range of substance abuse issues they target. Depending on a patient’s abuse habits and their medical histories, treatment periods can be as short as three months or can be considered lifelong commitments. Usually, patients require an individualized blend of treatments that include medication and behavioral therapy to cope with the major stages of recovery — from withdrawal to maintaining sobriety once it’s achieved.
How the Affordable Care Act Can Expand Your Coverage
While those are certainly high costs, even with coverage, both insured and uninsured Americans should review their health plan before 2014. As of October 1st, citizens will be able to apply for insurance through the Health Insurance Marketplace. Not only will this allow people to comparison shop for health insurance, but also as part of the Affordable Care Act, policies through the Marketplace guarantee an essential benefits package comprised of 10 items. One of those items is coverage for both drug addiction and alcohol abuse treatment.
Though not everyone qualifies to get insurance through the new law, you can use to find out whether you’ll qualify, and you can calculate potential cost savings through the Kaiser Family Foundation’s online calculator. Because the Parity Act, mentioned earlier, is encompassed within the ACA, and because both pieces of legislation preserve state laws, these changes to health care should continue making it easier and more affordable to get coverage for drug and alcohol addiction treatment.
Keys to Holding Your Provider Accountable
As stated earlier, it’s essential to familiarize yourself with your healthcare plan and check your state laws before approaching your provider about expanding your coverage. You’ll be a stronger force to be reckoned with if you know your rights as a policyholder. For instance, if your insurer refuses to cover costs that were not pre-authorized, your state might very well have a law prohibiting this denial of service — In Pennsylvania, for example, the law states that “there’s no need to authorize or pre-certify treatment for alcohol and/or drug problems through your health insurance plan.”
You can also consult with state legislators, the state insurance department, or the Office of the Attorney General if your insurance company is denying you coverage or discriminating against you because of a need for addiction treatment. If you’re already in touch with an addiction treatment center, they can also be a good resource: the Hazelden Center, in Minnesota, for instance, states on their website that they “will work closely with insurance companies to streamline the process and ensure that the patient receives the maximum benefit available.”
While it’s not always an easy discussion, it’s important to stand up for your rights when working with your healthcare provider. Addiction treatment has been stigmatized for years, causing many who might have benefitted from this treatment to go without. Your fight for coverage helps further the cause of drug and alcohol abuse patients nationwide and paves the way to better coverage and health care for everyone.
Prevention and Addiction Treatment Resources
Individuals and families struggling with addiction need to count on a support network of treatment centers and prevention and recovery advocates. Turning to these organizations is an essential part of recovery, and also the best way to become involved in the effort to raise awareness of the hardships and dangers of addiction.
Please explore the resources below to learn more about the organizations helping addicts every day
Substance Abuse and Mental Health Services Administration’s (SAMHSA) 
SAMHSA’s Strategic Prevention Framework Components
SAMHSA’s National Registry of Evidence-based Programs and Practices
SAMHSA’s Behavioral Health Treatment Services Locator
Hazelden’s Resources for Treatment and Criminal Justice/Alcohol and Drug Prevention
Al-Anon Family Groups
American Society of Addiction Medicine (ASAM)
Alcoholics Anonymous
Faces & Voices of Recovery
Narcotics Anonymous
The National Center on Addiction and Substance Abuse at Columbia University
National Council on Alcoholism and Drug Dependence
Substance Abuse and the Affordable Care Act
(Valentino Therapy was contacted by Mark Griffon at the Addiction Treatment and Recovery Resource to post and publish this important information. We have used their material, as requested, and added some of our own. The hope is that it will help those suffering, which includes their loved ones.)

Be kind to yourself. Therapy helps.
Sharon Valentino, CA LMFT, MA, ChT, Psychotherapist
Licensed Marriage and Family Therapist (51746)




3030 Bridgeway, Suite 108, 
Sausalito, CA 94965, phone 415.215.5363
Serving the San Francisco Bay Area

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How Loved Ones Can Help Addicts

How to Support Someone With an Addiction or in Recovery

Self-Care Comes First

  • Take care of yourself first.
  • Take extra care of yourself at this time.
  • Set a stellar example of someone who takes care of themselves properly: eat very healthy foods & drinks, do not abuse any substances, no junk food that the addict observes, as that is a strong statement of lack of consistency.
  • Engage in some spiritual practice: meditation, prayer, yoga, nature, walking, join a church, etc.
  • Get clear that your life and your relationship with the addict will never be the same again.
  • If you do not practice unwavering self-care, don’t expect your addict to do so.
  • Get in therapy or a therapeutic support group or Al-Anon & stay there, as you will need a lot more support than you think. You will need it longer than you think.
  • Get a massage and a haircut, update your look & clothing. Be proud of your appearance. This is not the time to be sloppy in sweats. Appearance improves your mood. People will notice. Your addict will too, but may not comment.
  • Get moving. This is critical for your body & mind. Invite your loved one to join you. Go alone.
  • See your Dr. for a check-up. Stress does ugly things to your body & defense systems.
  • Find a way to get healthy, adequate sleep or you won’t have the energy to be strong & give help. Also, even you can’t “think straight” without consistent, sound sleep. Get help if you need to.
  • You will often feel like giving up, but will still worry & be in anguish.
  • Get clear: You cannot motivate anyone. You can’t even motivate yourself sometimes.

There Will Be Problems – Big Ones

  • Your addict will tell you lies – both large and small ones. The small ones will be ongoing and you will start to lie to yourself that what s/he says “might” be true.
  • Your loved one will consistently need to RUN AWAY, using the substance that provides that escape. No substance? Then s/he will run away physically and/or emotionally. You will feel they are trying to keep you away, and they are.
  • Running away is the essence of substance abuse. It’s avoidance. They have experiences, feelings and other problems that they are running away from because they have not learned to “feel the feeling” and then let it go – even if only for a few minutes. This is the main thing that distinguishes them from others. It is what causes them the most problems. It will continue to until someone teaches them how to recognize, feel and realize their discomforting feelings. It usually takes a professional.
  • The addict may not think they have a problem, or that it can’t be managed.
  • Your loved one may give lip service to never using again, but in their heart they think they can and will manage it better in the future.
  • You will come to doubt yourself and even your senses sometimes.
  • The addict is probably not afraid of dying, though they fervently wish it were not a long, painful process. Sweet, quick escape is what they sometimes even look forward to.
  • Many addicts feel that, even if it doesn’t show, they are moving in the right path and they don’t want to change anything, and you, especially, are not going to tell them what to do.
  • All addicts don’t want you to change anything and interfere with their privacy and freedoms. *
  • All addicts are very concerned that you want to control them, get too involved in their lives and their recovery. *
  • Your loved one isn’t very comfortable discussing the deep, personal issues with a professional. They particularly do not want to discuss them with you.
  • Many times your addict will use you.
  • Often, your loved will want nothing more than to get away from you. That will include getting physically away from you.

How to Help

  • There is no one way, no easy way, no fast way to help an addict.
  • Learn to set boundaries and stick to them. It may save a life, as an addict rarely sets any boundaries for themselves whatsoever.
  • Help your addict find joy. This is critical. Try to reconnect them with things they used to enjoy, while realizing their enthusiasm cannot be the same until they are well down the road to recovery and regaining health.
  • You will never persuade an addict to get sober. The decision and determination, which is the hard part, must come from within themselves.
  • Do not lecture, admonish, exaggerate your stress and ability to deal with the situations, especially do not yell, or criticize.
  • Realize that addicts are very tuned in to hypocritical behaviors in others, but not themselves.
  • Do not, under any circumstances, allow the addict to use in front of you.
  • Never buy for the addict or allow the substance to be in your presence, or your home, if you live together.
  • If you allow others to use AT ALL in front of your loved one, then you are part of the problem.
  • If you try to establish homeostasis (an organism’s natural need to go back to the familiar), you will encourage things going back to what they were like before addiction really took hold; you will put your addict in great danger. That was the very situation, interactions, tolerances, exposures to others using, the stressors, the looking the other way – the many behaviors that produced the ability for the addiction to get a firm grip.
  • If you tolerate someone’s using, or your own, do not expect your addict to respect you or listen to you about them getting well.
  • If there is a stressful situation involved in being around you (for whatever reason), the addict will want to use more or they will need to escape you. Two tough choices for all involved.
  • Do not put up with bad behavior. Name it and say it doesn’t work for you. That is enough. Saying it will likely need to be repeated. If this continues, you may need to take calm, thoughtful action. Be a model of how to deal with such situations, because your addict will copy you – either behaving quietly, yet firmly, or behaving distressfully, loudly, threatening… with little follow-through, drama, etc. They will copy you and return the favor and they will repeat those behaviors – positive or negative – with others.
  • AA’ers have said to me, “He came to treatment too soon. He was still wearing a watch”. Yes, it is true that hitting bottom is usually the catalyst. That bottom might be finally selling your watch, as there is nothing else left to sell. Sometimes, it is causing great embarrassment to oneself or losing a relationship or losing health in a serious way. Sadly, in my experience, it is rare to see someone ready to change until there has been some quite negative consequence to his or her behaviors.
  • Do not protect your addict from negative consequences due to actions that have already occurred. It may be your only hope for change.
  • Do not tell your loved one that s/he is an addict, it is a problem, bad things are happening and they need to change. They already know this. This knowledge is a great impetus to use even more.
  • If you want your addict to change, then you will have to change too. Be prepared.

How to Support Treatment

  • Encourage it and then let it go (whether an intervention is involved or not). You can’t make anyone “get it”.
  • Offer to be involved only to the extent your loved one will allow – don’t push.
  • Don’t be surprised when your loved one blames you. Some of it will be true in some way, or you wouldn’t still be involved with them. Have an open mind.
  • Expect your addict to tell hurtful lies about you in treatment, to AA, and others to justify their own behaviors. This will generally pass in time when they get honest with themselves and others. You will never forget it though.
  • Be honest, not brutal, don’t criticize or humiliate your loved one in treatment or in session.
  • You can only say what it has been like for you, without exaggeration.
  • This is something I look for in session: Are you behaving with drama, exaggeration, attack, anger, getting loud, crying much more than might be expected, threatening to leave, end the relationship or walk out of session, making the other person wrong, controlling or manipulating the session, interrupting, taking on the persona of the hurt/damaged one, are you the martyr? Look at these and see if it is getting what y
  • Change does not come quickly. Try to be patient.

* After many years providing addiction therapy, I feel comfortable with using the word “All”, as these are the things I’ve never found an exception to. * This was written for my Psychotherapy Group: Dealing With A Loved One’s Addictions

Be kind to yourself! Therapy helps.      Sharon Valentino, Valentino Therapy, Licensed Marriage and Family Therapist (51746), MA, CHT, LMFT, Psychotherapist, Masters Clinical Psychology Counseling

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Illegal Drug Addiction and Substance Abuse

Illegal Drug Addiction and Substance Abuse (Photo credit: