Seeking treatment for addiction recovery can be a financial challenge for families. The question on many people’s minds is, does my insurance cover drug treatment? The good news is that with recent healthcare reform makes alcohol or drug treatment eligible for coverage.
Insurance companies are prohibited from applying a lower level of coverage for substance abuse treatment. They must cover these services at the same coverage levels as all other areas of the plan. However, insurance companies have specific medical necessity criteria for covered services. Medical necessity is the clinical demonstration of a medical need for services as defined by each insurance company. Insurance payers create their medical policies based on clinical proof.
How Does My Insurance Cover Drug Treatment?
For instance, if you have a headache you try over-the-counter pain relievers before you consider going to the doctor for a clinical assessment. If you do go to the doctor, he or she will try prescription medications before they consider referring you to brain imaging. These medical necessity criteria are outlined in policies by the insurance company and indicate what must be done before a higher or lower level of care will be approved. As well, there are many different treatment models to choose from, and knowing which services will be covered can be tricky unless you know how medical necessity is evaluated and what questions to ask your insurance company.
Not all treatment centers accept insurance as the primary or sole payment source. If you want to know does my insurance cover drug treatment, they may require the initial month of service to be paid in full pending assessment of insurance coverage. Treatment centers refer to this process as an Insurance Reimbursement agreement. In an outpatient treatment setting, insurance companies only cover the specific time periods where the member is being treated and do not cover room and board, transportation or meals. Additionally, claims payment is largely dependent on the member’s commitment to his or her recovery, continually meeting medical necessity criteria.
Insurance Providers Work with Addiction Treatment Centers
Insurance providers employ therapists, physicians and psychiatrists to perform a regular review of the clinical information between both parties in partnership with the treatment facilities clinical staff. This team of payer clinicians typically have experience in the field of substance abuse and recovery that is born from years of practice in their area of expertise. They, along with the treatment center clinical staff, assess each person individually against payer medical necessity criteria, the personalized treatment plan, and the person’s medical history to determine if the treatment plan is effective. If the person seeking treatment does not demonstrate that he or she is engaged in their treatment, as noted through clinical treatment documentation, the payer can deny further coverage. There is a lot of red tape to figuring out the answer to does my insurance cover drug treatment.
Scenarios Answering Does My Insurance Cover Drug Treatment
For example, Susie Client came to treatment for alcohol and drug treatment at the insistence of her family. Her insurance authorized an initial stay of 10-days treatment with further days being dependent on review. Susie met with her therapist and created a treatment plan that indicated her participation in daily in group sessions, weekly individual therapy sessions with homework assigned and community meetings. Susie and her therapist created clearly defined goals and a plan to work on Susie’s primary treatment goals. This information was provided to her insurance company during the insurance review process. When the time came for a review between Susie’s therapist and the insurance company it went like this:
- Q: Has Susie been attending and participating in her group therapy sessions?
- A: Not with consistency; group notes indicate a lack of participation and Susie’s continued glorification of her substance abuse history.
- Q: Has Susie been completing the homework assignments given by her therapist?
- A: No, Susie excused herself from homework for various reasons, centered on her forced entrance into treatment.
- Q. Has Susie met any of her goals within the initial period of treatment?
- A. No, Susie felt “forced” into treatment. She was just biding her time until she got out.
- Result: The insurance company denied additional days. They stated that the client did not have a personal plan for recovery. Nor did she show commitment to her recovery.
Clinical Review of Treatment Plans
Most people do not understand how intimate the review process is. The payer’s clinical staff become very involved with the program’s clinical team. Understanding the depth of reviews with the insurance plan can help you manage your expectations for insurance payment.
Determining if your plan covers treatment for alcohol or drug treatment can be difficult. To determine what your insurance company covers, you can ask the following questions of your payer:
- Does my insurance cover drug treatment
- How does my plan cover substance abuse/drug and alcohol abuse treatment?
- Does my plan cover the programming offered by the treatment facility?
- PHP-Partial Hospitalization Program: Not necessarily in a hospital setting, this gives daily individual and group therapy for a minimum of 4 hours a day and up to 5 days a week.
- IOP-Intensive Outpatient Program: This allows for individual and group therapy for a minimum of 3 hours a day and up to 5 days a week.
- OP-Outpatient Rehab Program: This allows for individual and/or group therapy services billed by the hour with no minimum hours per day/week.
- Do I have Out Of Network (OON) benefits in the event the treatment facility does not have a contract with the payer?
- Are there pre-existing clauses in my plan that would prevent these services from being covered?
How Morningside Recovery Helps with Insurance Coverage for Rehab
At Morningside Recovery, we have a team of billing personnel to take the guesswork out of your coverage for you. We will verify if your plan has benefits for alcoholism rehab or drug addiction treatment. If you or your loved one enters our programs, we work closely with the clinical team. We ensure delivery of pre-certification and timely documentation to the payer. This ensures continual medical necessity approval. Denials happen but that is not the end of the line for our team. We will appeal medical necessity denials when possible, gathering additional information or scheduling therapist-to-therapist calls when necessary. As well, we communicate with the client, or the family to keep them up-to-date on the status of insurance coverage. Morningside Recovery takes pride in obtaining insurance reimbursement for families. We recognize life is stressful enough without adding financial burdens.
Information is key to knowing “does my insurance cover drug treatment or drug detox in Orange County?” You can always feel free to call Morningside Recovery 24 hours a day, 7 days a week at 855-631-2135 to speak with a skilled counselor about your options in paying for detox or rehab.