In the underwriting process, insurers evaluate what qualifies as binge drinking and alcoholism according to the recommended daily allowance of alcohol. Binge drinking is defined as consuming a large amount of alcohol over a short period of time. Alcoholism goes further with multiple drink per day, every day, as outlined by most insurers. The guidelines for daily drinking according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) are more than 4 drinks per day for men, or an average of more than 2 drinks per day over a 7 or 30 day period. For women, excessive alcohol consumption may be considered more than 3 drinks per day, or an average of more than one drink daily for a 7 or 30 day period. This varies based on each individual’s reaction to alcohol, and certain types of people are advised against drinking entirely, such as pregnant women and children.
To most insurers, drinking to a degree of risking your health is defined as two or more drinks on a daily basis. However, the amount you drink is not a factor in health insurance eligibility, and you will be approved for coverage no matter what an underwriter considers unhealthy.
Any lack of regard for your health can lead to major damage to personal health and our health care system. Because alcohol abuse, dependency and over-consumption can lead to liver damage and other health problems, it should be treated. Many policies will cover alcohol abuse treatment under the Patient Protection and Affordable Care Act, including large and small groups, individual plans and exchanges. Premiums will not be increased for having this problem, and you cannot be declined. This law also helps pay for the thousands of dollars spent on inpatient stays, medications and outpatient treatment prescribed to policyholders with alcoholism.
Alcoholism and Private Health Insurance: Past and Present
Health Reform and Mental Health Care
Though alcoholism is considered a mental illness, it will not get in the way of your eligibility for health insurance under Obamacare. Insurers are also unable to increase your premiums or restrict the types of covered care to which you have access. Mental health and substance abuse care are part of the essential health benefits covered by plans on state exchanges and private policies. While underwriting still takes place when you apply for a health plan, your medical history is not a factor in choosing the health plan you want from any insurer. Not all insurance plans will cover mental health and substance abuse care simply because of the law. It is still necessary to check the benefits offered in the plan you are applying for, whether it is through an employer or an individual health plan.
As a last resort, if no other plan covering these benefits is available to you, you can apply for coverage on your state’s online health insurance marketplace, the exchange. Also, be sure to check the coverage levels and specific benefits on the various exchange plans if you plan to use your coverage for treatment.
Applicants who were at risk of further health problems because of the amount of alcohol they consumed, requiring medical treatment, would be rated up or declined for coverage before the health care law took effect. Those who applied for coverage and were considered excessive alcohol users were at risk of being declined. Those who apply and seem at risk were usually required to take a liver function test, and the results determined whether or not they were approved.
Below is an example from one of our national carriers’ underwriting guidelines in 2012. “IC” means that for each applicant they would individually consider your case, based on other health factors and determine your risk. In most circumstances, those who are under individual consideration experience an increased premium, not a full decline of coverage. This condition would be judged according to health, present level of alcohol consumption and DUI history as the basis for acceptance or rejection.
Some comprehensive individual health plans cover limited amounts of treatment for substance abuse, including alcoholism. In most plans throughout the country, there is an inpatient maximum benefit for a certain number of days the plan will cover, if they cover it at all. Outpatient services for alcohol abuse treatment are also limited in number of visits you can use per year before you will pay entirely out-of-pocket. These services are considered separately from other types of outpatient and inpatient hospital care, and not usually covered for the same percentage of coinsurance.
Coverage will also depend on the area in which you live, and the carriers available. HMO plans are typically more accommodating than PPOs for mental health and substance abuse coverage. Below is a section of the schedule of benefits for an individual Kaiser Permanente HMO plan, whose substance abuse services are affordable compared to a PPO in most cases. Obamacare plans on the exchanges are somewhat modeled after the one below, though they vary by state. For a copay of $20 per visit after deductible, an individual with this type of health need can receive care. It is important to check the plan details and outline of benefits before deciding on a health plan to make sure what you need is covered.
Other Insurance Options for Alcohol Abuse
Mental health and substance abuse coverage might be covered by every insurer in the next state over, but not yours, depending on what states and insurers decide to cover. Also, individuals with a very low income may qualify for Medicaid coverage. Large employers who offer their workers health benefits may cover care for alcoholics, especially due to the regulations established by health reform for benefit requirements. Whether an individual plan is too expensive or you would rather enroll with your employer than buy your own coverage, you have choices and can get covered.
Group Health Insurance
Most insured Americans have a plan through their employer at a large business, which may be offered if you are such an employee, married to one or a dependent child of one. While coverage will not be restricted to anyone based on their health status, many workers with preventable illnesses and conditions are encourage to participate in wellness programs to reduce their risk of further health problems. For people who drink too much, this may come out on a health risk assessment test, and your employer is likely to encourage you to take control of your health. Obamacare also sets rules for employer wellness programs, making sure your boss offers you a gym membership and other incentives to get healthy. With these rules in place, more sick people will be encouraged to improve their health and help keep premiums down.
If your condition is in need of treatment, a group health plan may cover such services, depending on the type of policy they provide their workers. Most group plans are HMOs, which offer comprehensive benefits and many options for common services within their provider networks. This means if you decide you need medical help controlling your alcohol intake, it will potentially be covered by your group plan. Always check your health plan to see what is covered prior to receiving a service so you know what to expect.
Medicaid and CHIP
Low-income individuals who abuse alcohol will also not be declined for coverage by Medicaid or CHIP, unless they do not meet their other eligibility guidelines. While income requirements vary by state, Medicaid is typically offered to parents, adults with disabilities, the elderly, pregnant women and children. Certain states have taken the hint from health reform to include low-income adults without children or a disability, which gives a greater population access to public coverage. CHIP is offered to children under 19 whose household income exceeds the Medicaid limits, and can be subsidized or paid for.
Many, if not most CHIP and Medicaid programs cover treatment for substance abuse and cover all medically necessary types of treatment. This would include testing and treatment for liver failure, as well as medications and other types of care that may be required by a person with alcoholism. Depending on the state and the program, Medicaid services are free of charge or very low cost with participating providers or clinics.
Your state’s health insurance exchange is a good back-up plan in case you do not qualify for or cannot afford any other type of coverage. Especially targeting the uninsured population with low to moderate income, plans sold on the marketplace allow you to apply for tax credits to reduce your premium, and subsidies to cover the cost of your care. Sold through a state- or federally-operated website, plans on the exchanges are available in four tiers: bronze, silver, gold and platinum. Each state exchange will cover all categories of essential health benefits, including treatment for substance abuse.