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What If Insurance Doesn’t Cover All the Treatment I Need?

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What If Insurance Doesn’t Cover All the Treatment I Need?

The Substance Abuse and Mental Health Services Administration (SAMHSA) tracks addiction care and related health issues, and its 2012 Treatment Episode Data Set (TEDS) report estimated that 1.82 million addicts entered a substance abuse program in 2010. The number of rehab patients who listed insurance as the primary source of payment was more than double the number that listed self-pay. Health insurance policies are a valuable financial aid for addicts seeking treatment, but the coverage is rarely 100 percent. Insured patients have deductibles and co-pays, and the plan might exclude certain services including the following:

  • Residential treatment for first-time addiction patients necessitating outpatient care
  • Medically assisted and/or tapered detox solely to reduce discomfort
  • Certain medications, out-of-network rehab facilities and optional rehab services
  • Holistic therapies for personal comfort and chronic pain management

Allowable treatment days might be limited, and patients or the rehab staff must regularly request additional days. Copays might also increase the longer a patient stays in rehab, and certain policies might limit total treatment costs. Addiction treatment can be expensive, and even a fraction of the cost not covered by insurance can be a burden. Nevertheless, when a gap exists between coverage and cost, options do exist.

What If Insurance Doesn’t Cover All the Treatment I Need?

Insurance Policy vs. Benefits

Whether intentional or accidental, insurance companies do not always live up to their policies’ benefits. If the promised benefits fall short of the reality, several responses are available including the following:

  • Call the company and make sure the denied or limited benefits were not a mistake.
  • File a formal written appeal with a doctor’s statement declaring medical necessity.
  • Request an independent review (if allowed by state law) by the state insurance agency.
  • Make use of any available third-party insurance reviews and watchdog programs.

The Mental Health Parity and Addiction Equity Act (MHPAEA) says most insurance policies must provide the same benefits for addiction and mental health services that they provide for physical health care. In association with the law, the Parity Implementation Coalition created the Parity Toolkit in 2010 to assist with denied claims.

Best Way to Utilize Insurance Benefits

Options decrease if the treatment is current or already occurred, but addicts seeking treatment have more opportunities to ensure benefits and decrease cost including the following:

  • Ask the insurance company to provide its medical necessity standards in writing.
  • Talk to the insurer about their process for getting treatment benefits approved.
  • Do not assume that all rehab benefits are automatically approved.
  • Request a full clinical assessment to diagnosis all physical and mental health issues.
  • Take the assessment to the insurer and ask what treatments they will cover.

Insurance companies want to limit fraud and abuse, but this creates additional hurdles and hassles for addicts with legitimate health needs. Nevertheless, people who take the right steps before treatment often have fewer insurance problems later.

Furthermore, the Affordable Care Act (ACA) mandates addiction treatment benefits for all policies on its health care exchanges, and insurers cannot deny benefits due to a preexisting condition. If it is an open-enrollment period, addicts without insurance should look into an ACA policy with favorable treatment benefits.

Ways to Manage Treatment Costs

If the insurance company will/did pay the benefits according to the policy terms, additional cost management options might apply including the following:

  • Ask the rehab center about financing options and payment plans.
  • Inquire about potential aid resources that might be available.
  • Consider a rehab center with a sliding-scale payment system.
  • Look into out-of-state facilities that might have reduced rates.

A 2010 National Survey of Substance Abuse Treatment Services (N-SSATS) report found that 38  percent of treatment centers have a sliding-scale fee schedule based on a person’s ability to pay. Check with the rehab center if your income level might qualify for financial assistance, and possibly seek out facilities that offer such benefits. Moreover, different potential scenarios might apply depending on the type of treatment needed including the following:

  • Residential rehab patients who run out of days allowed might switch to a state-sponsored facility or outpatient program.
  • The need for additional aftercare therapies might be met through government health programs and community organizations.
  • Certain charities and non-profits might have opportunities for free or low-cost addiction and mental health services.
  • Recovering painkiller addicts with chronic pain can check chiropractic and holistic schools for reduced treatment rates.

Addicts with multiple life issues (e.g., homelessness, mental health disorders, illiteracy) should see if a government case manager can help advocate for assistance and services.

Addiction Help Center

Regardless of the insurance benefits, addiction treatment is always worth the expense. Over the long term, rehab is usually more cost effective than extended substance abuse, and the financial impact of addiction-related job loss, accidents, health issues and legal problems can be much more costly.

Our admissions coordinators can help. We can discuss treatment, facility and financing options, and we can even look up insurance policies and explain their benefits. If a loved one is the addict, we can also assist with intervention information and referrals for professional interventionists. We are available 24 hours a day, so whatever the need, please call our toll-free helpline now.

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