Frequently asked insurance questions
When contemplating treatment for addiction or a mental health disorder, an important consideration is whether your insurance plan will cover at least some of the cost. Because of the proliferation of health insurance plans on the market, each with varying criteria, it is difficult for a treatment provider to make a blanket claim about insurance coverage. Each prospective patient has unique insurance requirements for the various levels of care, depending on their plan.
That said, here is a list of frequently asked questions regarding insurance.
1. Does insurance cover treatment for cannabis (marijuana) abuse or addiction?
No, cannabis abuse is not covered by insurance companies for treatment in a high level of care; unless the cannabis addiction is in addition to another substance addiction or mental health diagnosis.
2. If my insurance allows me to receive unlimited treatment, will it cover this program?
Not necessarily. Treatment via an insurance plan is authorized based upon the patient meeting specific medical criteria requiring them to be in a clinically monitored setting.
3. I have been off drugs for more than a week now and want to enter a residential treatment facility. Will I qualify for insurance benefits?
Possibly. If a patient has been able to remain sober from substances for more than one week after a relapse, insurance may sometimes not authorize treatment. However, depending on the patient’s current symptoms, insurance may authorize.
4. What does it mean when they say “must meet medical necessity?”
Meeting medical necessity requires the service the patient is requesting to be reasonably designed to treat, cure or prevent worsening of the condition that endangers their life, causes suffering or pain or results in illness that may worsen if left untreated. A patient must present with specific symptomology showing they are meeting medical necessity.
5. What is meant by different levels of care?
Detoxification treatment, residential care (RTC), partial hospitalization (PHP) and intensive outpatient services (IOP) are popular levels of care. The level of care approved by insurance will be based upon the doctor’s recommendation after evaluation of all the patient’s conditions and symptoms. Certain disorders require a higher level of care, and other conditions can be effectively treated at a lower level of care.
6. What do I do if the insurance company denies coverage based on their doctor’s review of my case?
If the insurance company’s doctor does not authorize care due to a patient not meeting medical necessity, a peer review can be requested. The insurance company doctor will consult with a representative from Sovereign to discuss your case to arrive at a decision. If the insurance company’s doctor denies the care, Sovereign has the option to request an appeal. If the appeal is denied by the patient’s insurance company, the patient or their family has the option to contact the insurance company directly, to legally appeal the denial or to arrange for private pay.
7. I have serious depression, where I often consider suicide, am unable to sleep, have no appetite and generally feel hopeless. Does this meet medical criteria for a high level of care?
Yes, this does constitute a medical necessity, though the level of care will be determined by the physician after evaluation.
8. It has been recommended that I complete a 30-day program. Will my insurance pay for all of that time?
Not necessarily. Insurance plans often place limits on the number of days of treatment that are covered.
9. What is the difference of “in network” and “out of network?”
These terms pertain to the healthcare provider and whether or not they are participating in your insurance company’s provider network. If not, meaning the provider is “out of network,” your costs for services will be higher, in some cases substantially higher.
10. Does my insurance carrier cover detoxification?
Each insurance provider is different, so you would need to inquire as to whether your carrier covers detox.
With the passage of The Mental Health Parity and Addiction Equity Act of 2008, (MHPAEA), the federal law that provides participants who already have insurance benefits for mental health, and substance use disorders (MH/SUD) parity coverage, providing Americans help for their drug addiction with better coverage. The MHPAEA law, called the Wellstone/Domenici Parity Act, basically says that insurers must provide the same benefits for substance abuse as they do for other medical conditions. The Parity Act and healthcare reform bill reflect an understanding that addiction is a disease and that those struggling with this chronic condition deserve effective treatment as part of their regular healthcare.
These FAQs provided by Sovereign Health. For more information on your specific plan, call your insurance representative directly or contact Sovereign Health Addiction, Dual Diagnosis, and Mental Health treatment programs at (866) 795-6602 or visit them online at www.sovhealth.com.