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Getting Your Addiction Treatment Claim Approved & Paid
Insurance for addiction treatment is a complex beast to navigate. From deductibles and copays to the amount of coverage included in any particular plan, insurance providers tend to cover a wide number of overall addiction treatment costs. This means you can expect to run into different coverage amounts for things like lengths of stay in treatment, whether or not detox is required, levels of care (inpatient vs. outpatient), and the providers available for you to choose from (in-network vs. out-of-network status).
Talk to Your Insurance Provider Pre-Treatment
Call the Member Services department at your insurance company to learn more about addiction treatment options. Have your insurance card and membership identification number handy. Take notes and write down the name of the member representative who you are speaking to and the date of the call. Do not be afraid to ask questions and clarify new terminology.
In order to get insurance to pay your claim, there are several questions you’ll want to ask your insurance provider:
What’s Your Plan Type?
The most common types of insurance plans are:
- Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
- Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
- Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
- Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
- Medicaid plans tend to vary, as individual states can establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines.
- Medicare plans can range greatly in coverage, depending on whether you have original Medicare, Medicare advantage, additional prescription drug coverage, or Medicare supplement insurance policies (medigap).
What Are the Details of Your Coverage?
Keeping in mind that requirements may be different depending on the level of care you are seeking: detox, inpatient, outpatient, partial hospitalization, intensive outpatient, or aftercare. To get insurance to pay your claim, you’ll want to know the coverage and care details for all of the following:
- Lengths of stay
- Stage of treatment
- Levels of clinical care, and contracted
- List of in-network providers.
Ask Your Representative for the Following Essentials
- Is There a Search Radius for Eligible Providers?
Some want to attend a rehab on the other side of the country, while others want to stay as close to home as possible. If there’s an established search radius for providers, that could narrow your search significantly.
- Do You Need Prior Authorization, Pre-Approval, or a Referral?
If you need one of these before you can enter treatment, but you are unaware of this mandatory step, it simply adds more time to your wait list.
- What’s Your “Maximum Out-of-Pocket Expense” for Rehab?
Be sure to ask your representative for the costs and co-pays associated with each and every different treatment option.
- Get a Copy of the Provider’s Criteria for Determining Medical Necessity for Rehab
When you know the criteria for approving addiction treatment, you’re already one step ahead of the game, should you be issued a denial letter and need to file an appeal.
- Ask for a List of All In-Network Treatment Providers
This step will significantly cut down on the time it takes to find a treatment center or provider that’s right for you. It’s a waste of time to focus on a provider who you later find out is out-of-network (and out of your price range).
Get Insurance to Pay Your Claim By Knowing Your Rights Under the ACA
Under the 2008 Mental Health Parity and Addiction Equity Act (Parity Act), private and public insurers are obligated to provide comprehensive and equitable coverage for substance use disorder and mental health benefits. The Parity Act requires a health plan’s standards for substance use and mental health benefits to be comparable to – and no more restrictive than – the standards for other medical benefits. Generally, this means that a plan cannot put more restrictive visit limits, impose higher cost sharing or apply more rigorous prior authorization or concurrent review requirements on MH/SUD benefits as compared to similar medical benefits or surgical benefits. For example, if your plan allows for 20 visits for outpatient physical therapy, then it must allow the same number of visits for mental health counseling.
The Affordable Care Act requires plans sold on the marketplaces (individual and small group plans), as well the Medicaid expansion plans, to cover substance use disorder and mental health benefits as “essential health benefits.”
If you are unsure of your specific benefits, look at your insurance plan’s certificate of coverage to determine your coverage. This generally can be found on your insurance carrier’s website and if you are still unsure, call your insurance carrier to clarify. You can use the phone number on the back of your insurance card.
What Treatment Settings and Medications Are Covered?
Effective care for addiction is provided in different treatment settings or levels of care. The appropriate level of care should be determined by a medical professional, based on a comprehensive assessment of your unique needs and situation. This assessment creates a foundation for an effective treatment plan and will determine the level of care that is most appropriate.
Your plan may offer both inpatient and outpatient treatment. Inpatient treatment may include detox treatment in a hospital or a residential treatment facility. Outpatient treatment may be provided in a doctor’s office or clinic. There are also “intermediate” services, which include intensive outpatient and partial hospitalization programs, both of which are outpatient services.
This is where the importance of an evaluation is clear. If you are placed in a lower level of care than what is needed, your needs may not be addressed properly. However, if you’re placed in a higher level of care than needed, you may receive unnecessary treatment at a higher cost.
The use of medications, psychosocial therapies, or both in combination (medication assisted treatment) may be necessary. Medications are an effective and, for some forms of addiction, a critical component of treatment.
Ask your insurer what medications it covers and for how long. There are currently three FDA-approved medications to treat opioid addiction: methadone, buprenorphine and naltrexone. Each medication works differently and may be available in different treatment settings.
