En español | Parity laws such as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equality Act of 2008 require group health insurance plans to cover mental health and substance abuse issues in the same manner as the plan covers medical issues. But it can be difficult to ensure that a patient has the coverage needed for recovery, says Elizabeth Hill, clinical director of the Blake Recovery Center at Carrier Clinic, a mental and behavioral health treatment center in Belle Mead, New Jersey. Insurance companies often include fine print, which covers the treatment only if medically necessary — a condition that may be subjective, depending on the opinion of the health care provider, she says.
Yet substance abuse among adults age 50+ is projected to double from the 2.8 million annual average in 2006 to 5.7 million people in 2020. That makes coverage of addiction issues a matter of increasing urgency.
To ensure the best possible coverage under your current plan, here are 7 essential steps.
1. Check Your Policy. The question of exactly what is covered begins with the insurance policy itself, so be sure to get a hold of your policy or benefits book and read it carefully, says Dr. Fred Berger, medical director of the Scripps McDonald Center in La Jolla, California. Policies may have in-network and out-of-network benefits, which are covered at different levels depending on an insurer’s agreements with various facilities. In addition, some facilities may not accept insurance, but require payment in advance, leaving the patient to pursue reimbursement from the insurance company. Berger adds that Medicare coverage of inpatient detoxification programs "is typically very good."
2. Understand Treatment Options. Not all treatments are equally effective — or equally covered by insurance plans, says Mandie Conforti, LCSW and a consultant at Towers Watson, a human resources and risk management consultancy in Chicago, Illinois. Before managed care became prevalent, she says many people would go for extended, fully reimbursed stays in treatment facilities in California or Florida. However, managed care companies began questioning that approach, since the triggers for relapse are often in the home. Because of that, she says, many cover outpatient treatment that guides patients through the trials of remaining substance-free in their home environment. Hospital-based treatment programs may be covered differently from residential treatment programs, as well, she says. Finally, be sure to ask about and abide by any requirements for authorizations, pre-certifications, or referrals.
3. Note Underlying Conditions. Common underlying medical conditions, such as high blood pressure, heart disease, or chronic pain may add cost and risk to substance abuse treatment, and they need to be included in the treatment program, says Berger. Depending on the situation, those underlying issues may require more intensive treatment than would otherwise be needed, he says.
4. Keep Records. Write down dates and details of conversations with your insurance company prior to and during treatment, as well as the name and, if possible, the title and other identifying details of any representatives, says Linda Schmidtt, president of Medical Professional Solutions, a medical billing company in Richardson, Texas. Ask the facility for an itemized list of expected charges and ask your insurer for a copy of the authorization letter. Also, ask your physician for a list of diagnosis codes for any conditions that will be treated, she says. By gathering as much detail as possible, patients have documentation to counter any disputes by the insurance company.
5. Work with Your Team. A person fighting addiction is often not in the best frame of mind to keep abreast of details and fine print, says Berger. Enlist a family member or friend to help you navigate the process. In addition, he says, work with your doctor and the staff of the treatment facility, who often have resources to verify insurance coverage and create the best possible treatment protocol for the coverage you have.
6. Speak Up. Hill finds that many patients are so eager to get better that they under-report their symptoms, saying they feel better than they really do. When progress is relayed to the insurance company, the length of stay or treatment may be reduced.
"Older people are more apt to not want to be a bother, but we can only report what you say. So, it's very important to be as honest as you can be about what you’re feeling," she says.
7. Know Your Rights. If your claim is denied, it's not the end of the road, says addiction treatment veteran John Lieberman, who is currently the director of operations at Visions Adolescent Treatment Center in Malibu, California.
"If you get denied, the insurance company should also tell you or send you a letter stating what the next [step for appealing] is," he says. "You can request a further review. You can have your primary care physician make the phone call to make a further request," he says.
If such contact doesn't yield results, Lieberman advises consulting your state insurance commissioner's office, which governs the insurance industry in each state. (Find your state's.) You can also contact your state Attorney General's office. Doing so can be an effective way to protect your rights and coverage, he says.