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Choosing where to go for addiction treatment often involves considerations about health insurance coverage. Do you know how to get the answers you’ll need? Learn what to ask your health insurance provider here.
Once you’ve made the decision to go in for treatment, the most important hurdle is already behind you. Next, however, comes a series of decisions you need to make: where to go for treatment, what kind of treatment is best for you, how you’ll pay for it, what are the potential outcomes, and much more. While you reflect on what to do next, before you throw up your hands in frustration, look at these must-ask questions for health insurance providers. The more knowledgeable you are upfront about what’s covered and what’s not, the easier your decisions about addiction treatment will be.
GATHER YOUR INSURANCE DOCUMENTS
A critical first step is to locate your insurance documents and read through them to know the specific wording of your policy, as well as what your policyholder rights are with respect to addiction treatment coverage. Look for wording that defines the “full continuum of addiction treatment,” which should include intervention, detoxification, inpatient or residential rehab, outpatient treatment, as well as intensive outpatient, family, and codependency treatment. Your goal here should be to become as knowledgeable as possible before you get in touch with your health insurance provider.
MAKE A LIST OF QUESTIONS YOU WANT TO ASK YOUR INSURANCE PROVIDER
After reviewing your policy coverage, you’ll likely have many questions. Be sure to write them down so you don’t forget anything important during your conversation with the health insurance provider.
PRACTICE WITH A FRIEND BEFORE YOU CALL
As with anything you undertake that has potential life-changing implications, you want to come off as informed, confident and hopeful when you speak with the representative at your health insurance provider. It might be helpful to practice with a friend what you’re going to say or at least how you’ll begin the conversation.
DON’T BE INTIMIDATED – THIS IS YOUR LIFE AND YOU OWE IT TO YOURSELF TO FIND TREATMENT THAT’S BEST FOR YOU
While this is all new to you, keep in mind that health insurance providers get these questions all the time. As such, you may feel that they’re in possession of more information than you have available to you. However, you are the customer and have rights as a policyholder. Remember that what you’re asking for and seeking is appropriate and medically necessary. And, also keep in mind that many insurance companies offer generous coverage for drug and alcohol rehab programs and treatment services for their insured policyholders to help them overcome their addiction. However, even if the initial answers you receive aren’t sufficient to ease your mind about paying for addiction treatment, you’ve made a good start. There are other options you can explore, should it come to that. For now, be thorough and decisive in contacting your health insurance provider and discussing coverage for the addiction treatment you need.
CHECKLIST OF QUESTIONS TO ASK INSURANCE PROVIDERS
What specific questions should you ask your health insurance provider about getting the addiction treatment you need covered? Start with the basics and expand from there as more questions come to mind during your conversation with the health insurance provider representative.
Levels of Care
Ask about the levels of care your policy covers for addiction treatment. While some health insurance plans are more generous than others in this area, covered levels of care should include the following:
- Intensive outpatient treatment (IOT)
- Partial hospitalization
- Continuing care or aftercare
In-Network and Out-of-Network Providers
Another key area to discuss involves in-network and out-of-network providers. In addition, ask what percentage your insurance covers for each. Bear in mind that you’ll typically pay more for out-of-network addiction treatment providers and must obtain pre-authorization for treatment. If you can find an in-network provider that you want to go to for addiction treatment, and your policy covers much, most or all your treatment, that’s likely the best option.
Deductibles, Coinsurance and Co-Pays
You’ll want to find out the deductible you’ll be required to pay as well as any coinsurance and co-pays per covered service. You should know that according to the Mental Health Parity and Addiction Equity Act, health plan features such as deductibles, co-pays and visit limits generally are not more restrictive for mental health and substance use disorder conditions than for medical and surgical benefits. Still, as a rule, the lower your monthly health insurance premium, the higher your coinsurance (the amount you pay after you’ve met your deductible). Co-pays are usually a fixed amount when you receive a covered service or fill a prescription. Keep in mind that you may have to pay coinsurance and co-pays in some instances.
Be sure to discuss what your maximum out-of-pocket expense will be. This is the most that you or your family will pay for covered essential health benefits before your insurance plan starts to pay 100 percent of the addiction treatment or services costs. Mental health and substance use disorder services, including behavioral health treatment, are covered essential health benefits included in the out-of-pocket maximum. While deductibles, coinsurance and co-pays are included in out-of-pocket expense calculations, insurance premiums are not, nor are balance billings from non-network and other costs from out-of-network providers, or spending for nonessential health benefits.
Criteria for Medical Necessity
Ask what criteria your health insurance provider uses to determine medical necessity. According to HealthCare.gov, medically necessary refers to “healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”
WHAT IF YOUR INSURANCE COVERAGE ISN’T ENOUGH?
Suppose the addiction treatment or drug and alcohol rehab center you’ve selected as the best suited to treat your substance use disorder isn’t an in-network provider under your health insurance plan? Or, the limits in your coverage mean you’ll need to pay more than you can afford? Don’t give up. You still require treatment and there are other options for you to explore.
After you know what your health insurance provider will or will not pay for addiction treatment, get in touch with your chosen treatment provider and ask about payment assistance in the form of sliding pay scale or ability to pay programs. Other facilities may be able to link you with federal, state, or local agencies for various payment assistance programs. The addiction treatment facility may also offer scholarships or grants to help pay for treatment. You can also consider financing that may be available through the treatment facility, or through your bank, credit union or other means of assistance, including personal loans from a family member.
Other forms of health insurance may cover all or part of addiction treatment services. These include VA and TRICARE assistance, Medicare, Medicaid, and others. For example, the Veterans Administration offers treatment for eligible alcohol and drug dependent veterans, so if you’re a veteran or are currently serving in the military, you may be able to get treatment paid for through them.
DON’T BE EMBARRASSED TO ASK FOR HELP
Sometimes the very best thing you can do to get your insurance coverage questions answered is to ask for help. In many cases, addiction treatment providers will work with your insurance company on your behalf to determine your level of coverage before you begin treatment. At Beach House Center for Recovery, our admissions counselors are available 24/7 to answer insurance-related questions free of charge. To get trusted answers, call us today at 1-855-544-6542.
Benefits.Gov, “Veterans Alcohol and Drug Dependence Rehabilitation Program.” Retrieved June 17, 2017
Blue Cross Blue Shield Blue Care Network of Michigan, “How do deductibles, coinsurance and co-pays work?” Retrieved June 17, 2017
Department of Health and Human Services, Centers for Medicare & Medicaid Services, MLN Matters, “Medicare Coverage of Substance Abuse Services.” Retrieved June 17, 2017
HealthCare.gov, “Medically Necessary.” Retrieved June 16, 2017
CMS.gov, Centers for Medicare and Medicaid Services, The Center for Consumer Information & Insurance Oversight, “Mental Health Parity and Addiction Equity Act (MHPAEA).” Retrieved June 16, 2017
National Center for Biotechnology Information (NCBI), National Library of Medicine, National Institutes of Health (NIH), “Aftercare in drug abuse treatment.” (PubMed.gov) Retrieved June 17, 2017
National Center for Biotechnology Information (NCBI), National Library of Medicine, National Institutes of Health (NIH), Bookshelf, “Substance Abuse: Clinical Issues in Intensive Outpatient Treatment.” Retrieved June 17, 2017
National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), Frequently Asked Questions, “What is detoxification or ‘detox’?” Retrieved June 17, 2017
National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), Media Guide, “The Science of Drug Abuse & Addiction: The Basics, How are drug disorders categorized?” Retrieved June 17, 2017
National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), “Screening, Assessment, and Drug Testing Resources.” Retrieved June 17, 2017
National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), “Treatment Approaches for Drug Addiction.” Retrieved June 16, 2017