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Substance Use Disorder (SUD) treatment is becoming unaffordable because of high deductibles and copays.  Through the health insurance marketplace there are opportunities available to help individuals choose the appropriate insurance coverage, enabling access to SUD treatment and other services at an affordable cost.  Low premiums can be deceiving.  Plans with lower premiums could have higher copays and deductibles.  This can result in higher overall costs.

Open enrollment for the federal health insurance marketplace is November 1, 2016 to January 31, 2017.  Because plans change, all participants in the insurance marketplace should be encouraged to reassess their options each year.

The plans in the marketplace are arranged by metals:  Bronze (60%), Silver (70%), Gold (80%) and Platinum (90%).  For a bronze plan, an insurance company is projected to pay 60% of costs, leaving the consumer responsible for 40%. While a bronze plan may have the lowest premium, the overall cost to a consumer could be significantly higher once they use health care services.

The Advanced Premium Tax Credit (APTC) is a federal subsidy for those individuals and families that earn up to 400% of the Federal Poverty Level.1   For 2016, a family of four from Pennsylvania with an income level of $97,000 could qualify for a subsidy.2   This premium assistance is available for any plan on the federal exchange, but the amount of assistance is based on a household’s income and is relative to the cost of the silver plan.

A second subsidy, called a Cost-Sharing Reduction (CSR), is available to help cover the cost of copays and deductibles.  When a Marketplace application is filled out, the applicant will find out if they qualified for these extra savings. This cost-sharing assistance is only available to consumers who qualify and choose a silver plan through the marketplace.3   The federal government does not offer assistance subsidies for employee-based coverage, which may also have high deductibles and copays.

While many individuals in need of SUD services would qualify for the federal assistance subsidies of premiums, copays, and deductibles, many are purchasing insurance from the marketplace’s least expensive option, the bronze plan.  This makes them ineligible for the Cost-Sharing Reduction.  In the long run, this could be costly, providing many with unaffordable health insurance coverage.

For this reason, stakeholders (Single County Authorities, case managers, treatment providers, recovery organizations, advocacy groups, etc.) should encourage people to explore their options during open enrollment.   They can also engage the free services of a Navigator, an individual who can assist in determining the best insurance options for a particular person, and utilize the “Total Cost of Care Calculator.”

1 October 7, 2016, “Premium Tax Credit,”
2 October 7, 2016, “Saving money on health insurance,”
3 October 7, 2016, “Cost-Sharing Reduction,”