The federal government is touting low premium costs for the health insurance marketplaces, and without looking closely at health plan details, consumers might think that buying health insurance on the “marketplaces” under healthcare reform is inexpensive and will guarantee them what they have been putting off because of cost — including possibly treatment for a substance use disorder (SUD). But a closer look shows that they will have to pay 40 percent of the treatment costs out of their own pockets if they have the least expensive health plan based on premium cost, and 20 percent if they have the most expensive. For SUD treatment, that “cost sharing” can add up. And unlike a broken leg or appendicitis, SUDs are something that people tend to ignore — partly because of the cost of treatment — until they have reached a crisis. That is exactly what the Affordable Care Act (ACA) was supposed to avoid.

Insurance companies have for many years used copayments and deductibles as utilization control tools targeted at consumers. But the ACA, in the policies provided under the exchanges, allows this tool to go farther than ever before, on a wholesale basis for the select group of patients who can’t afford health insurance without a subsidy, or who are uninsurable due to a pre-existing condition. While on the one hand the ACA will allow for more coverage for everyone, it will also require patients to pay out of their pocket, up until they reach a certain limit. For that reason, SUD treatment providers should plan on insurance covering only 60 percent of services, for patients in the least expensive “bronze” plans, and on figuring out how to get the rest from the patient (insurance companies take a dim view of “writing off” costs, and you can lose your network status if you take that route).

A report released September 25 by the Department of Health and Human Services (HHS) highlights the low premiums that will be available under the health insurance marketplaces but says little about cost sharing — the 40 percent of people who sign up for bronze plans, 30 percent for silver and 20 percent for gold will have to pay, in direct healthcare costs, up to more than $6,000 for individuals and $12,000 for families.

Enroll your patients

Of course, having 60 percent of the costs paid is better than having none of it paid, and crisis treatment often costs in the tens of thousands of dollars, and it’s in the treatment provider’s benefit to have insured patients. So treatment providers should be prepared to help new patients sign up for insurance, said Ron Manderscheid, Ph.D., executive director of the National Association of County Behavioral Health and Developmental Disability Directors. “Number one, providers need to know that they can go to, hone in on their own state and bring forth an application form for the person to complete right there,” Manderscheid, who is also co-chair of the Coalition for Whole Health, told ADAW.

The treatment provider should help with the application form, he said. “I’ve been preaching this for months,” he said. In addition, treatment providers should work with the health insurance navigators in their respective state. For states with federally facilitated marketplaces — states that refused to set up their own — there are grants to help with applications, said Manderscheid.


However, on the down side, it’s not clear that SUD providers are fully included in networks yet. Although the ACA requires that there be network adequacy, this is largely monitored by the state insurance departments, who, according to Gary Cohen, director of the Center for Consumer Information and Insurance Oversight (CCIIO) of the Centers for Medicare and Medicaid Services, are doing a good job of this. Speaking during a September 24 press call about the HHS report on low premiums, Cohen, himself a former state insurance director, did not specifically refer to SUDs, however.

Manderscheid said that treatment providers need to reach out to insurance companies to make sure they are included in exchange plans. “The network piece is not worked out yet,” said Manderscheid. “I always encourage providers, including the counties, to reach across the aisle, to offer to become a behavioral health provider.” Noting that under the ACA insurance companies can’t cut out SUDs and mental illness — it’s one of the ten essential health benefits that must be on the exchanges — insurance companies may welcome a provider who can fill what in the past may have been a gap in their coverage.

In addition, insurance company networks are different depending on whether the plan is inside or outside the exchange, notes James Newhouse of Newhouse Financial Consulting in Rye Brook, New York. So consumers will have to do their research before trying to sign up to find out if a provider they want is in a certain network, Newhouse told ADAW. In general, there are many more plans to choose from outside than inside the exchange, he said, but those plans don't have subsidies.

Newhouse cautioned that the websites for online enrollment "are extremely complicated, and consumers should use a broker or assister to help them." In Connecticut, for example, "if you mess up one question, the site locks you out," he said.


But no matter how well prepared providers are, there is bound to be a lot of confusion among consumers as healthcare reform rolls out, said Chuck Ingoglia, vice president for public policy at the National Council for Behavioral Health. The community behavioral health centers that constitute National Council members are trying to get signed up with insurance companies, but most uninsured patients are more likely to be eligible for Medicaid, he said.

In many areas, commercial plans as well as nonprofit plans operate the Medicaid behavioral health system, and these Medicaid plans have “a lot more incentive” than the qualified plans on the exchanges to contract with mental health and SUD providers, said Ingoglia.

The problem is that even if patients come to treatment providers ready to pay their cost sharing, if the provider isn’t in the network, the patients will be stuck with paying even more — maybe all — of the bill.

But many states haven’t even come out with their qualified plan on the exchanges yet, said Ingoglia. And on the commercial side for those exchanges, plans have a vested interest in keeping the network small, so they can keep costs down by steering most of the patients to a few providers. “This is a concern that we have, that we hear from our members — plans aren’t contracting with them,” said Ingoglia.

Asked about limited provider choices on the exchanges, the CCIIO's Cohen said in the press call on premiums that the trend toward smaller networks preceded the ACA, and is just part of the insurance companies' efforts to keep costs down. If healthcare plans aimed at the lower middle class who need subsidized insurance can’t contract with community-based entities like National Council members, it’s hard to believe that they will contract with higher-priced treatment facilities, whether for SUDs or mental illness or both, despite the ACA requirement that the networks have adequate behavioral health providers.

Ingoglia and Manderscheid both said that the federal government wants to hear about what is working and what isn’t, and wants to get any problems fixed. But enrollment itself is probably going to be a problem, especially for people with SUDs, they said. “Think about what happened with Medicare Part D — there was a captive audience, and an auto-enrollment process for people who didn’t sign up,” said Ingoglia. “This is all voluntary — you have to go out and search for options.”


Meanwhile, managed behavioral healthcare organizations (MBHOs), the insurance companies that specialize in covering SUDs and mental illness, “are trying to increase the number of providers in their networks in preparation for the increase in the number of individuals with health insurance,” said Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness, a membership organization representing those insurance companies. “This is true in all sectors: health insurance marketplace, Medicaid, Medicaid Expansion and the criminal justice population.”

The ACA and the Mental Health Parity and Addiction Equity Act will expand behavioral health coverage for 62.5 million people by 2020, said Greenberg. “Together, the laws will allow 32.1 million individuals to access substance abuse benefits for the first time and expand behavioral health coverage for 30.4 million individuals with existing behavioral health benefits,” she said. “Given these statistics we certainly expect utilization and demand for substance use treatment to increase.”

Bottom Line…

Treatment providers expecting the previously uninsured to flock to their doors seeking care should be prepared for the cost-sharing provisions of the health plans offered for the first time in marketplaces.