From the Pennsylvania Insurance Department – As part of Governor Wolf’s effort to battle the opioid crisis, the Pennsylvania Insurance Department released a brochure to help people battling opioid addiction understand what substance use disorder treatment (SUD) is covered by their plan, depending on how they get their health care coverage.
“The coverage available for substance use disorder treatment varies by the type of health care coverage an individual has, so it’s important for anyone needing treatment and their families and support group to understand how this coverage may vary,” Insurance Commissioner Teresa Miller said.
The brochure, “Substance Use Disorder and Your Insurance Coverage”, was first made available today at a meeting on the opioid crisis held by the Roman Catholic Diocese of Greensburg, at Our Lady of Grace Parish in Greensburg, Westmoreland County.
The brochure outlines how the source of health care coverage impacts what SUD treatment coverage options an individual has, or whether this treatment is covered at all.
If you have coverage through government programs:
- If you have Medicaid (also called Medical Assistance) or CHIP, you have SUD coverage. Check with your program to find out exactly what benefits you have.
- If you have Medicare, you may have coverage depending on the type of treatment you need. Check with your program to see if you are covered.
If you have coverage through the individual market:
- If you buy health insurance yourself at healthcare.gov, or directly through an insurance company or agent, you are covered for SUD treatment as long as the plan complies with the Affordable Care Act.
If you have coverage through an employer, you may or may not be covered.
- Many companies are self-insured, meaning the company pays the claims itself even if it hires someone else to do the paperwork. Self-insured companies are NOT required to provide SUD coverage, but many do.
- If your company buys coverage from a commercial insurer, Pennsylvania law guarantees you are covered for SUD treatment.
- Talk with your human resources department to find out if your company provides SUD treatment.
“Another important point explained in the brochure is that if you do have SUD coverage, the insurance plan must offer the same level of benefits as it does for medical or surgical treatment. This is called parity,” Commissioner Miller said.
Examples of services that are subject to parity rules and must be covered at the same level as medical or surgical benefits are:
- The number of outpatient visits
- Out-of-pocket costs, such as co-pays, deductibles, and co-insurance
- Prior authorizations requirements
- Your provider network for out-of-network services
- Criteria used to determine medical necessity
“Governor Wolf’s expanded Medicaid program and the availability of individual plans through the Affordable Care Act are providing access to SUD care for approximately 175,000 Pennsylvanians. Understanding what treatment consumers can get under their coverage is a vital part of accessing this care,” Commissioner Miller said.
The “Substance Use Disorder and Your Insurance Coverage” brochure is available on the Insurance Department website: www.insurance.pa.gov.