If you have chronic pain, the Affordable Care Act requires your health plan to offer certain services and benefits that can help you.* For instance, your plan must cover prescription drugs. You will also have better access to pain counseling through your family doctor.
But some questions remain. Whether you will be able to use some treatments for pain may still depend on what state you live in or on your particular health plan. Your insurance may not have to cover acupuncture or chiropractic care, for example. This may depend on where you live. Also, pain clinics are not required to be part of your plan’s network, although some plans may include them.
Pain Management Benefits
If you bought a health plan through your state’s Marketplace, on the individual market, or have insurance through your small employer, your health plan must cover a core package of benefits under the Affordable Care Act called essential health benefits. You may still have to meet your deductible first and pay a portion of the cost, except for some preventive services. While health plans offered by large employers are not required to include these essential health benefits, almost all do. The pain management benefits include:
- Prescription drug coverage
- Chronic disease management
- Emergency care
- Hospital care
- Mental health services
If you have Medicare, your plan includes the essential health benefits. So does Medicaid if you qualified due to your state's expansion of Medicaid.
Pain Treatment and Counseling
Most of your pain management care should come from your family doctor. There are also specialists in pain clinics that focus on people with more complex cases. Check with your insurance company or employer to see if these specialists are included in your plan.
Depression and Mental Health Treatment
You might feel depressed or anxious because of your chronic pain. You can get free screening for depression under the new law. You also can get mental health treatment for depression, anxiety, and other mental health conditions.
Alternative Medicine
You might be able to have acupuncture or see a chiropractor for your pain. This depends on where you live and the specifics of your plan. That's because states can choose whether to include these services as part of the essential health benefits package.
Most states include chiropractic care as an essential health benefit. Only a handful of states - California, Hawaii, and Utah - do not.
On the other hand, very few states include acupuncture. Only Alaska, California, Maryland, New Jersey, New Mexico, and Washington include acupuncture as an essential health benefit. Other states may follow.
Remember, if you get your health plan through your employer and your employer has more than 50 employees, your employer gets to choose what benefits to include. Most large employers cover the essential health beneifts, but whether they cover acupunture or chiropractic care varies.
Medicare provides very limited coverage of chiropractic care. It does not cover acupuncture.
Savings on Drug Costs for Seniors
If you're on Medicare and take medicine for chronic pain, you may be pleased to know that the donut hole -- the gap in Medicare coverage for prescription drugs -- has changed significantly. Now you pay just 25% of the cost of your brand-name and generic medications. See What Medicare Costs, Part D to get the details.
*Grandfathered health plans -- those that have been in effect since before the ACA passed and have not substantially changed -- as well as short-term health plans -- those that provide coverage for less than one year -- are not required to provide the essential health benefits.
