Drug Addiction and Mental Illness: Got Coverage?

by Deanna Lear

     If you had a heart attack, your health insurance would pay for emergent medical care, maintenance medication, and follow-up care. If you were in the midst of a manic episode or struggling with a heroin addiction, your insurance most likely would not cover treatment. If your insurance provider does offer benefits for addictions and mental health treatment, it has the ability to identify which substances and mental health conditions are worthy of coverage. Don’t be fooled into thinking that simply because you have insurance, it will cover your bipolar disorder or anxiety disorder the same as it will your heart condition. 

     Mental health and drug addiction affect us all. The person in the cubicle next to you at work could be struggling with a cocaine addiction. Your best friend may be feeling deeply depressed and considering suicide, or maybe your neighbor is displaying erratic and unusual behaviors. Even though their struggles may be hidden, they are real. According to the National Alliance on Mental Illness (NAMI), approximately 61.5 million Americans are living with a mental illness. That is roughly one in four people. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports approximately 8.9 million people living with both an addiction and mental illness. (This is commonly referred to as a co-occurring disorder.)

     For years, advocates have been pushing for insurance companies to pay for mental health and substance use disorder treatment as they would for medical conditions. This is referred to in the law as parity. Under the Affordable Care Act (ACA), mental health and substance use disorders are considered an “essential health benefit.” This means that individual plans available on the Health Insurance Marketplace offer benefits that cover mental health and substance use disorder treatment equally with medical benefits. The ACA requirements apply to  all small group and individual market plans created after March 23, 2010. For those with other plans, such as those provided by large employers, it’s more of a gamble. Although the Mental Health Parity and Addiction Equity Act (MHPAEA) passed in 2008 to address the issue of unequal coverage, there are many exemptions to MHPAEA, and employers and insurance companies are still able to get around the law.

     Many employers are not required to offer coverage under the MHPAEA. The law only requires that employers who do offer coverage for mental health and addictions treatment "to offer coverage for those services that is no more restrictive than the coverage for medical/surgical conditions." (SAMHSA, 2014)

     Those who reject parity often cite its costs as a concern. However, parity is necessary for the well being of our nation. Preventative medicine is being recognized as a cost savings, as this approach allows illnesses to be detected and treated early, leading to improved outcomes in long-term health.

     I argue that we should be looking at mental health and substance use treatment in the same way. To only treat a person’s physical health without treating his or her mental health or drug addiction is negligent. Additionally, while it is within the legal rights of an insurance company to determine which diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM) it will cover, by not providing coverage for all diagnoses, the stigma around certain disorders will remain. It is interesting to note that all federal employees and their families have complete coverage for all diagnoses listed in the DSM, as well as all related treatment. For the rest of us, it’s a crap-shoot.

     It is time to close the gaps in mental health and addiction treatment coverage. It is not enough to say treatment is available if it is difficult to access. Removing systemic barriers to treatment allows the opportunity to dispel the stigma surrounding mental health and addictions. Reducing stigma allows people to feel more comfortable obtaining treatment. This will lead to an improvement in the quality of their lives and the health of our nation.

     As social workers, we need to help lawmakers understand the importance of requiring that group health plans offer coverage for mental health and substance use disorders and limit exemptions to parity through continued advocacy work. In addition, social workers should educate the people they serve about mental health and addictions parity, so they can be informed consumers and feel empowered to reach out to politicians and demand something better than unreliable coverage.

     If you have a question or complaint regarding your health plan’s coverage of mental health and addiction treatment, you can contact the Department of Labor at www.askebsa.dol.gov. Additional information about mental health parity can be found at SAMHA's Mental Health Parity and Addictions Equity page and the U.S. Department of Labor Mental Health Parity page.

Deanna Lear is a student in the part-time MSW program at the University of Pennsylvania’s School of Social Policy and Practice with an expected graduation in May 2016. She has been working in the behavioral health field since graduating from Lycoming College in 2007 with a Bachelor of Arts degree in sociology. She currently lives in Lansdale, PA, and works full time as an Intensive Case Management Supervisor for a nonprofit agency in Philadelphia, PA, serving adults living with a substance use disorder. Her areas of interest include suicide, self-injury, and personality disorders.