Rehab and Medical Insurance– Are you covered? (And what the ACA can do for you)

Obviously, treatment for substance abuse is worth whatever it costs, because it can save your life. That doesn’t mean that it isn’t expensive, with the tab for four to six weeks of inpatient treatment at some facilities running as high as $30,000. Most of us don’t have that kind of money sitting around, which is why insurance coverage is so crucial for getting the treatment you need.

Most employer insurance policies cover at least part of the cost of treatment. If you or a loved one is considering entering a rehab facility, you must meet with an agent for your insurance provider first and discuss exactly what is covered, and more importantly, what isn’t. Be prepared to ask some very important questions.

What you must ask your provider

For starters, when does your insurance cover rehab, and for how long? In what situations are you covered? Are you covered if you have been treated previously, or is this considered a pre-existing condition? Do you need a referral from a primary physician in order to be covered? Which treatment centers are covered under your plan?

There are several types of treatment that are often covered by health insurance. One is detoxification, which require 24-hour monitoring within an inpatient setting. Another is outpatient drug treatment, which does not involve 24/7 monitoring, and the patient does not live in the same place he is being treated. With inpatient drug treatment, the patient lives in the same place where he is being treated. This model is also called residential treatment.

Getting approved

It’s practically impossible for a “civilian” to wade through the thousands of words of legalese contained in the average health insurance policy to get down to the nitty gritty of “Am I covered for drug/alcohol rehab treatment?” The answer lies in the concept of “medical necessity.”

The majority of insurance companies will accept or reject your request for coverage based on medical necessity, which has several core components as defined by the American Association for Addiction Medicine. First, that the requested treatment services are required to diagnose and/or treat a suspected or identified illness or condition. Second, that the requested treatment services are appropriate for the condition as well as meeting the standards of good medical practice. Third, that the treatment requested is required for more than just the convenience of the requester or provider.

The latter is meant to screen out potential patients who could be treated in a less costly outpatient program but prefer to check into a residential facility. For the insurance companies, there’s a fourth component—that the requested treatment is not more expensive than any other treatment that is as likely to produce similar results.

Can you meet the criteria?

The insurance company is going to try to get away with paying as little as possible, since that’s how they stay in business. In order to get them to approve your treatment, you will be expected to meet certain criteria. One is that your withdrawal symptoms can be managed at the level of care you request. Another is that you must be cognitively able to actively participate in a rehab program. Finally, you must prove that you desire treatment and have the motivation to work toward recovery.

After jumping through those hoops, the insurance provider is likely to have a few more for you, like whether you are at risk of harming yourself or others. If not, you probably won’t be approved for the more expensive inpatient care. You may also need to prove that you have severe medical problems that make it impossible for you to get sober outside of a residential environment. They may ask for evidence that the less expensive outpatient care would not work in your case, so be prepared to show that previous attempts have failed. Another factor in approving a request for residential care is showing that your current living arrangements are dysfunctional and harmful to your chances of recovery.

Keep detailed records of your conversations with your insurance company, including the names and titles of those you dealt with. Try to get an itemized list of possible charges from your chosen facility and go over it with your agent. Gather as much documentation as possible in case of disputes later.

If you aren’t getting the answers you want from your insurance provider, it’s time to get help. Most drug treatment facilities have years of experience in dealing with the ins and outs of the insurance industry. Find an advocate who understands your needs and what can be done to get you into the type of facility that can help you with recovery.

The Affordable Care Act

This month, consumers can begin shopping for health insurance at state exchanges created by the Affordable Care Act, aka “Obamacare.” What does this mean to those seeking coverage for treatment of substance abuse issues, or those who have been treated in the past? For one thing, you cannot be denied coverage for pre-existing conditions, so if you have been cancelled in the past due to issues with drugs or alcohol, you should definitely look into your options under the ACA. The aim of the Affordable Care Act is getting all U.S. citizens insured, whether through their employers, Medicare, Medicaid or private companies. Hopefully, this will encourage more persons suffering from substance abuse issues to seek help.

Mental health and substance abuse issues are directly addressed by the ACA.  According to the Washington Post, “Under the Affordable Care Act, insurance plans offered in the new marketplaces will have to cover a core set of services called ‘essential health benefits.’ Included on the list of 10 benefits are mental-health and substance-use disorder services, which include behavioral health treatment, counseling and psychotherapy. Specifically, as part of what’s considered preventive services, plans will also cover alcohol-misuse screening and counseling, depression screening for adults and adolescents, domestic and interpersonal violence screening for women, and behavioral assessments for children.”

If you’re having problems dealing with your insurance company, do not give up. Your life and your health are at stake, so don’t give up on getting help. If you need to get health insurance, go to www.healthcare.gov for more information.

Have you had problems getting your treatment covered by insurance?

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