Best Insurance Options for Rehab

The decision to seek treatment for a drug or alcohol addiction is a serious undertaking, one that works best when thoroughly planned and carefully considered. For the majority of clients, insurance coverage and benefits become a critical factor in the decision making process, and there are many complexities involved. Fortunately, universal healthcare made possible by the Affordable Care Act (ACA) and protected status of those in recovery has opened up new vistas, with greater flexibility than ever before for those seeking treatment.

Unlike previous decades—when insurance companies consistently fought or denied coverage for a variety of reasons—the paradigm shift that accompanied the passing of the ACA in 2010 works to the advantage of those suffering from addiction and/or behavioral health problems. Although there is no one-size-fits-all insurance plan, the following article will explore best options and provide a summary of the basic coverage process.

REHAB COSTS REQUIRING INSURANCE COVERAGE

There are many costs associated with drug rehab, and coverage depends upon the specifics outlined in each plan. While certain plans may cover all—or the majority—of costs, others are more limited in the coverage they provide. It is extremely important to understand the pros and cons of each insurance option so that out-of-pocket costs are reduced and the best possible coverage is provided for the duration of treatment.  

INITIAL DETOX

Detox is a crucial component of drug rehabilitation that involves eliminating toxic substances from the body prior to beginning treatment. Many legal and illicit substances have withdrawal periods that are considered dangerous and unpredictable. This is the primary reason why initial detox requires hospitalization. Hospitals provide the medical management and supervision necessary to ensure a relatively safe withdrawal process and prevent precipitated withdrawal—the potentially fatal acceleration and intensification of symptoms.  

HOSPITALIZATON, INPATIENT, AND OUTPATIENT TREATMENT

Costs associated with treatment vary widely. Although many insurance companies cover outpatient treatment, residential programs and hospitalization are handled separately.  Depending upon the quality and level of care provided by a facility, average costs can range from $1,000 to $25,000 or more. Due to the diversity of available rehab facilities, insurance options, and methods of treatment, it is impossible to predict exact costs involved. However, as a general principle, certain treatment centers offer premium quality options that require greater financial commitment.

PHARMACOLOGICAL INTERVENTIONS

Initial detox and subsequent treatment may require various physician-prescribed, Food and Drug Administration (FDA)-approved medications to treat the underlying causes of addiction, minimize cravings, and reduce the intensity of withdrawal symptoms. Under most insurance plans, such medication is referred to as pharmacotherapy. Although many plans cover pharmacotherapy, not all plans provide this necessity. Having a plan that provides for medication coverage is considered optimal and goes a long way toward reducing the financial concerns of those seeking treatment.

INSURANCE TYPES

Thorough investigation of all available insurance options is an excellent starting point for those seeking treatment. To those unfamiliar with the basics of the insurance process, coverage is divided into three primary categories—private, public, and group insurance.

PUBLIC INSURANCE COVERAGE

For the uninsured or those that are underinsured, public insurance programs such as Medicare or Medicaid may help provide the coverage needed. To understand how to qualify for public assistance, the website healthcare.gov provides the information necessary to see if this might be a viable financing option. Many facilities do not accept public insurance programs such as Medicaid and Medicare, so it is vital that you first consult the rehab facility of your choice.  Although some facilities are partially or entirely subsidized by the federal government, they have very specific guidelines for income in order to qualify. Another possibility is to find nonprofit organizations providing rehab services that allow participants to pay in manageable monthly installments—even after treatment has been completed.

PRIVATE INSURANCE COVERAGE

Private insurance is generally more costly than public insurance, but offers a comprehensive selection of programs and benefits when compared to government-assisted options. They are usually paid for by an employer, or an individual who may be self-employed. Other than the basic deductible, private insurance coverage typically pays a significant percentage of the cost of treatment, with minimal out-of-pocket expenses. It often covers premium inpatient alcohol or drug rehab, higher-end facilities offering a plethora of amenities including private rooms, excellent cuisine, fitness instructors, beautiful settings in desirable locations, etc.  It may also include holistic treatments such as yoga, acupuncture, massage, and meditation.

GROUP INSURANCE COVERAGE

Group insurance represents another excellent option for those seeking treatment. Historically, people struggling with addiction have feared taking advantage of benefits afforded them by employers due to shame, embarrassment, or the very real possibility of being fired. Fortunately, legislation including the Mental Health Parity and Addiction Equity Act of 2008 forces insurance companies to provide equal coverage for those in need of substance abuse treatment or other medical disorders. By most estimates, this legislation extends coverage to approximately 100 million qualifying employees.

HMO, PPO, AND POS PLANS

Most insurance plans are coordinated based upon providers within a specific network. This process—known as managed care—provides three primary care plans:

• Health maintenance organizations (HMOs)—these popular, affordable plans only extend coverage to in-network providers. They are sometimes criticized for their limited flexibility and freedom of choice. However, a primary benefit of HMOs is the minimal out-of-pocket costs due at doctor visits. For these reasons, HMO plans are considered the fastest growing managed care option, but most restrictive form of health care.

• Preferred provider organizations (PPOs)—like HMOs, these plans are geared toward in-network providers; however, many cover certain out-of-pocket costs. Although they offer the flexibility of allowing out-of-network visits, customers may be required to pay upfront or seek future reimbursement from the insurance company. Compared to HMO plans, PPOs are generally considered more flexible.

• Point of Service (POS)—POS plans offer the supreme flexibility of allowing customers to choose an HMO or PPO plan every time care is needed. The POS model, based on preventative care, is considered cost effective in the long run although the premiums are more expensive when compared to HMO plans.

KEY QUESTIONS

Insurance is a complex business and even very knowledgeable people frequently have questions or concerns related to their plan. For most people, speaking directly to an agent from their insurance company is the best way to become familiar with the range of coverage and services provided. Although some people resort to internet research to obtain answers or seek further information, there is a lot of misinformation and inaccurate claims that appear on-line. For those who make the effort to call, the following questions can help ensure your phone time is productive and alleviates some of your concerns:

• Are detox services provided by my plan? If so, what exactly is covered and for how long?
• Are specialty programs covered under the provisions of my plan?
• Is coverage provided for residential, or inpatient treatment? If so, what exactly is covered and for how long?
• Are prescription medications required for treatment covered?
• Is coverage provided for outpatient treatment? If so, what exactly is covered and for how long?
• Is there a co-pay involved in specific services?

PLANNING FOR TREATMENT

Those who take the time and effort to fully explore insurance options related to their addiction treatment will find themselves enjoying a more rewarding experience. Although treatment itself is considered stressful for many people, nothing adds more stress than being totally unprepared for the financial aspect of receiving professional help and unaware of possible options. Progressive health care legislation in recent years has created a wealth of resources available to those in need of treatment that previously didn’t exist, and there is never a legitimate reason or excuse to avoid confronting the disease of addiction.  

Remember, addiction is not a disease affecting only those with known substance use disorders (SUDs) or documented family histories of drug or alcohol dependence. Anyone, at any time, regardless of race, gender, socioeconomic status, age, or religion can find themselves struggling with addiction. If you or someone you love are struggling with addiction and in need of treatment, call a substance abuse professional today.

Never allow questions, fears, or concerns related to insurance coverage negatively affect your decision to seek help. Reputable facilities have trained admissions staff and insurance specialists available to help you navigate the process and arrive at a viable option, and most clients receive partial, if not total, coverage. Even in the rare event that coverage is denied, the possibility of scholarships, federal grants, and flexible payment plans will be discussed.    

For more about addiction treatment and recovery, check out these related articles:

• “Location is Key to Find the Best Treatment Facility For You”
• “Navigating Insurance: What You Need and What You Need to Know”
• “Financing Options for Rehab Treatment”
• “Traveling for Treatment? Here’s What to Pack for Rehab”

Sources:

1. American Journal of Public Health. The Affordable Care Act Transformation of Substance Use Disorder Treatment. Jan, 2017.
2. Facing Addiction in America. Health Care Systems and Substance Use Disorders. Nov, 2016.
3. PLOS ONE. Association between Drug insurance Cost Sharing Strategies and Outcomes in Patients with Chronic Diseases: A Systematic Review. March, 2014.
4. The AMA Journal of Ethics. How Should Therapeutic Decisions About Expensive Drugs Be Made in Imperfect Environments? Feb, 2017.