Controlling an addiction is hard to do alone. But with help, anyone can do it. Therapists can teach techniques to conquer cravings, medications can also help to manage cravings and withdrawal and even correct chemical imbalances caused by the addiction, and support groups can connect people with others who understand what they’re going through and can help them get through anything. Treatment works, and it’s the best way to recover from an addiction.
Unfortunately treatment comes with a price tag, and sometimes health insurance doesn’t cover the kind of treatment a person might want or need.
There are principles of health insurance that apply to rehabilitation programs. Talking to the insurance company or an insurance benefits counselor is the best way to understand rehab insurance. Health insurance can be confusing, and plans can vary from company to company and state to state. To get answers to specific questions about rehab insurance benefits, talking to someone in person or on the phone about a specific plan and how it works can often be the most helpful.
Health Insurance Basics
Employers provide health insurance for almost 68% of Americans between the ages of 18 and 64 years, and almost 18% of Americans receive coverage through the healthcare marketplace. For people covered through their employer, a representative from the company chooses a medical plan for all employees, whose coverage is fully or partially paid for by their employers.
Most insurance plans provide a form of insurance known as managed care. These plans were originally created to cut costs can have very specific rules and regulations in order to achieve that goal. For example, some health insurance plans require people to first see their doctor to obtain a referral for specialized treatment, such as rehab for a substance use disorder.
Some plans provide incentives to choose providers within a specific group by contracting with specific providers that are in-network. To keep costs low, the insurance company has agreements with these providers about how much they can charge. A person who chooses to use an out-of-network provider might have to pay some or all of the costs out of pocket.
When a person signs up for coverage, they are given information about what is covered and what is not, and how their insurance plan works. Someone who knows about insurance and is accustomed to reading legal language might be able to glance through these documents and understand what they need do to get coverage for addiction treatment. But someone who no longer has the information or does not understand what they are reading will need some help.
Insurance Terms Explained
Insurance company employees might seem as if they are speaking a different language when they discuss coverage and costs. Understanding a few common terms might make translation a bit easier:
- Covered services.These are the medical benefits the insurance plan will pay for. They might include medications, tests, or treatments.
- Medically necessary services.These are medically acceptable treatments that someone’s doctor might believe they need. Most insurance providers are more likely to cover at least some of the cost for treatments that have been deemed medically necessary. The designation does not, however, guarantee that the service will be paid for.
- Deductible. If someone’s insurance plan has a deductible, that person is responsible for payment of covered services up to that amount before the insurance company pays for covered services.
- Copayment. This is a set amount of money that someone must pay for a specific type of treatment, provided that the deductible has been paid if applicable.
- Annual limit. The insurance plan might limit the number of treatments a person can receive, or it might place a dollar amount on what it’s willing to cover in a year.
- Denied claim.If someone agrees to a service and their provider bills the insurance company for that care, the insurance company can refuse to pay the bill. This is a denied claim, and the bill often becomes the patient’s financial responsibility. This situation can occur if the treatment isn’t medically necessary or isn’t covered under the person’s insurance plan.
- Appealed claim.If the company refuses to pay a bill, a person can enter a formal notice through an appeals process indicating that they disagree with the decision to refuse payment and why they think the bill should be paid.
Understanding an Insurance Plan
Someone who has lost their insurance packet can contact their human resources director for another copy or may be able to view the packet online. They shouldn’t be afraid to ask, and they don’t have to mention that they would like to look at the manual because they’re dealing with an addiction. They can simply say that they have lost their copy and they’d like a replacement. No additional information is required.
Someone who can’t understand what the plan covers and doesn’t cover has a few options:
- Speak to the customer service department.Health insurance plans often have phone numbers conveniently listed on the insurance cards provided so that members may call to hear an explanation of their benefits. A representative can walk through the person’s health insurance plan with them, outlining how the coverage works and how they can access it.
- Speak to the insurance sales staff. Companies sometimes use sales brokers to buy insurance, and these people know a significant amount about the plan sold.
- Speak to the doctor. Many doctors are familiar with the insurance coverage provided by the plans they accept. If they don’t accept a certain plan, they might be willing to ask their receptionists or support staff members to research the issue for the person who’s considering treatment.
- Speak to the provider. Addiction counselors and treatment facilities can be good sources for insurance information. They might deal with these issues every day and know a significant amount about how the plans work and what they cover.
The Law, Addiction, and Insurance Coverage
In order to ensure that people have the coverage they need to deal with an addiction issue, lawmakers have crafted rules designed to improve coverage and access to care. One of the most important changes – commonly known as the Mental Health Parity and Addiction Equality Act – was passed in 2008. This act requires that insurance plans covering mental health and substance use disorders provide equivalent coverage for these services to that available for medical or surgical coverage, with similar deductibles, copays, and treatment limitations.
At first glance, this rule sounds ideal. But there’s a hitch: The law doesn’t require plans to cover mental health or substance use treatment. Plans can get around this law by providing limited or no coverage for mental health problems or they can strictly reduce the type of coverage they provide for these problems. If they limit coverage this way, they technically still might be in compliance with the law even if they don’t provide the sort of coverage a person needs to deal with their addiction issue. Plans also might not cover enough time in treatment.
Most states require insurance plans to cover some form of addiction therapy, but these states might put strict limits on the sorts of coverage plans offer, and co-payments might be high. Other states don’t require this sort of coverage at all.
The Affordable Care Act (ACA) – also called “Obamacare” – names substance use disorder treatment as one of the 10 essential elements of health care coverage, and it ensures that all health insurance offered through the health insurance exchanges or by Medicaid must cover treatment of substance use disorders.
Rules and regulations regarding insurance are always changing, and they’re often hotly contested. Typically, however, rules don’t go into effect until the year after they’re established. If the news reports about new coverage or changes to existing coverage, that information might not apply to a person until their plan comes up for renewal.
The information in a person’s benefits packet is more reliable regarding a specific plan than information that person hears on the news. That packet contains more information that applies directly to the person now, as opposed to information that might apply in the future. The person can also call their insurance plan directly for the most current coverage information.
Dealing With Denied Insurance Claims
If someone’s insurance plan sends them a letter of rejection, there are options for fighting back and ensuring that they get the coverage they’ve paid for. Consider these steps:
- Contact their state insurance department and ask for advice on the claim. Their plan might be denying coverage that the state requires insurance companies to pay for.
- Ask their provider for help. Sometimes, a person’s provider might have paperwork to submit that can demonstrate that they need the treatments they’re getting.
- Document everything. A person fighting a denial of a claim should keep copies of all their records, all their letters and all their bills so they can refer to them if questions come up. If they’ve spoken to or emailed their insurance company, they should keep records of this communications and of who they spoke to.
- Keep your insurance company sales representative informed. Sometimes, these people can work with the insurance company to override rejection letters and get the person the proper coverage. Representatives are motivated to keep clients happy so they can make the next sale. As a result, they could be that client’s greatest ally.
Help for the Uninsured
While the availability of insurance coverage has increased dramatically in the United States in recent years, many people still have no insurance coverage. Statistics are not yet available for recent years that include coverage under the ACA, but the most recent survey results show that in 2012, 58.3% of individuals admitted to substance use treatment were uninsured. Many of these people might be covered under the ACA, which makes insurance coverage more available to low-income individuals and families. However, the effects this availability will have on treatment statistics are currently unknown.
Even without health insurance, there are options available for people to get the care that they need. Sometimes, people go through addiction treatment programs provided through their county health departments. Other times, their poor health status and low incomes allow them to qualify for state medical health insurance, through which they then have coverage for addiction. In addition, many treatment facilities offer sliding-scale costs or payment plans to help make treatment more feasible for people with limited funds.
Concerns about payment shouldn’t keep someone from getting the help they need to deal with an addiction. If a person has insurance, many people are on hand who can help them get the care they need. If an individual doesn’t have insurance, other people can help them get coverage or access to services that don’t require coverage.
The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a national helpline that provides round-the-clock, cost-free substance abuse treatment information and referral services to uninsured and underinsured individuals. Solutions are available to those who need them.
If you or a loved one is struggling with an addiction and want help, call 1-888-744-0789 Who Answers? to speak to a rehab placement professional who can guide you through treatment options and help you get started on the road to recovery.
- Centers for Disease Control and Prevention. (2016). Health insurance coverage.
- S. National Library of Medicine. (2016). Managed care.
- S. Centers for Medicare and Medicaid Services. Glossary.
- Substance Abuse and Mental Health Services Administration. (2016). Laws, regulations, and guidelines.
- National Conference of State Legislatures. (2015). Mental health benefits: State laws mandating or regulating.
- Office of National Drug Control Policy. Substance abuse and the affordable care act.
- Substance Abuse and Mental Health Services Administration. (2016). The CBHSQ report: The substance abuse prevention and treatment block grant is still important even with the expansion of Medicaid.