Based on data collected by the National Survey on Drug Use and Health (NSDUH) from 2010 to 2013, approximately 20.2 million Americans needed treatment for a drug or alcohol abuse or dependence and were not receiving the necessary care in 2013.
In addition, 31.4 percent of those who perceived a need for treatment and didn’t receive it cited a lack of health care coverage or cost as the primary reason for not getting the help they needed. The amendments to the Affordable Care Act (ACA), which took effect in 2014, seek to change these numbers and make substance abuse treatment more accessible and affordable for more people. These laws may improve insurance coverage and treatment options, making up to five million people currently facing drug and alcohol abuse problems eligible for coverage, as published by Fox News.
The ACA makes substance abuse disorders one of the 10 elements of essential health benefits, classifying addiction as a mental health disorder, and federal parity laws dictate that mental health disorders be covered by insurance in equal manner to how other medical or surgical procedures are covered. This means that if you have a group health plan under your employer, are covered through the state, or have a plan purchased from the Health Insurance Marketplace, you potentially have coverage for a substance abuse disorder that may include detox services. Federal parity laws may make mental health treatment more readily accessible to more than 82 million Americans, according to the National Alliance on Mental Illness (NAMI).
Questions to Ask Your Insurance Company
Every insurance policy and company may be different and may handle detox and substance abuse treatment services at varying levels of coverage. Understanding the different types of treatment can help you ask the right questions when talking to your insurance company about what they cover.
Residential treatment refers to a comprehensive treatment model wherein you stay at the facility for a set amount of time in order to receive intensive therapies, counseling sessions and sometimes detox services. Detox is the process of purging drugs or alcohol from the body and may require the use of medications through medically managed detox in order to safely remove the toxins. Outpatient treatment may also include detox services as well as therapy and counseling sessions, although you will return home each night. Detox is often best performed in a residential setting with medical care and supervision from consulting physicians. Clarify with your insurance company exactly what they will cover and how you will pay for the remaining amount before entering into any form of treatment.
There are some important factors to consider and things to ask in order to determine what your insurance policy may cover, such as:
- Do I need a referral? Often, insurance companies will require that your primary care physician refer you to drug or alcohol treatment directly before paying for coverage. Some may require an official diagnosis before covering drug or alcohol treatment programs.
- What types of substance abuse treatments are covered? Some insurance companies may cover only outpatient treatment, for example. Others may require that you first attempt outpatient treatment and fail before it will cover residential care as well.
- What is considered a medical necessity? Insurance companies may only cover services they deem “medically necessary.” As withdrawal from many drugs, such as opioids, is generally miserable but not considered life-threatening, often medical detox may not be considered necessary treatment. Determine up front if your insurance company has this clause or if they will pay for detox even if it is not deemed life-threatening.
- Will you cover detox treatment at a specialty or luxury treatment facility? Some insurance companies may only cover detox at predetermined facilities or locations, while others may cover certain in-network facilities at a higher percentage and allow you to pay the remainder of the costs out of pocket for an out-of-network treatment facility.
- Can I still be covered at a facility that is not in my network? Yes, generally speaking you can receive treatment from an out-of-network provider, although you may pay more to do so. In-network providers are covered more fully and at higher percentages than out-of-network providers.
- How long of a stay in detox is covered? This is important, as many detox programs may be longer than what your insurance is likely to cover. Be sure to understand exactly how many days your policy will cover; many policies cite 28 days as the maximum length of coverage for medically managed detox, for instance. Sometimes detox treatment is only covered a set amount of times for the lifetime of the policy or within a given year, also meaning that if you are seeking treatment for a relapse episode, you may need to pay associated costs on your own.
- What is the maximum amount of coverage for detox services allowed? Most insurance policies will have a cap on the total amount they will cover in a year or the lifetime of the policy, and some facilities may cost more than others. Be sure to be aware of the particular costs of your chosen detox program and how much of this your insurance will cover.
- Will there be any out-of-pocket expenses? Many insurance companies will expect you to pay a co-pay or a percentage of the treatment. Sometimes you may have a set deductible that you will have to reach before coverage kicks in as well. It is important to prepare for any associated costs you may be responsible for.
- How are co-occurring disorders covered? Half of all drug abusers and one-third of alcohol abusers also suffer from mental illness, according to NAMI, and when these disorders occur simultaneously in the same person, they are said to be co-occurring. You may need referrals from both a primary care physician and a mental health professional for the treatment of co-occurring disorders, which are most effectively treated with integrated and simultaneous care.
- How are payments handled? Detox and rehab facilities may bill your insurance directly to pay for services, while others may bill you and you may be responsible for seeking reimbursement from your insurance company.
Cost vs. Benefit
Understanding insurance and what it may or may not cover can be tricky, and not all policies are created equally. Drug and alcohol treatment facilities may accept only certain insurance policies or coverage from specific insurance companies. Sometimes your employer may cover some of the costs associated with drug and alcohol treatment as well. In the long run, drug or alcohol abuse is likely to cost you more than the cost of detox and rehab even if you have to pay for some of the services yourself. The National Institute on Drug Abuse (NIDA) estimates that illegal drug abuse costs the American society $181 billion a year while alcohol abuse costs $185 billion each year. These costs are related to a loss of production in the workplace, health care costs and legal or criminal justice costs.
Addiction treatment programs may provide cost savings at a dollar-to-dollar ratio of 12 to one overall, as published by NIDA. Experts at The Oaks at La Paloma can help you navigate your insurance policy and ensure that you are getting the best possible coverage under your current policy. Highly trained staff members can speak directly to your insurance company in order to maximize your benefits and provide you with the highest level of care. There are no hidden fees and all costs will be discussed up front. A free, confidential and comprehensive assessment will be provided in order to determine what level of care will best suit your individual needs. The professionals at The Oaks at La Paloma can help you recover with confidence. Call now to learn more.