Deciding to get help for your drug problem can be scary, stressful — and incredibly courageous. If you’re confused about whether your insurance company covers drug treatment in full or in part, you’re not alone. Here is some information you need to know about health insurance while you’re on the road to recovery.
- Is drug rehab covered by my plan?
Not all health insurance plans cover drug rehab. A law passed in 2008 requires health insurance companies to offer some drug and alcohol treatment coverage to group health plans for businesses that have no fewer than 50 employees. That means that many people, including those with health insurance, do not have coverage for addiction treatment. Your health benefits summary will tell you if drug rehab is covered by your plan and what type of coverage you’re entitled to. You can also call your insurance company to discuss your plan in depth.
- What is the difference between an HMO and a PPO?
An HMO (health maintenance organization) and PPO (preferred provider organization) are managed healthcare plans that contract with doctors, hospitals and other healthcare providers and services. An HMO will often require that patients select a practitioner from in-network providers and obtain a referral for specialized treatment, such as drug rehab, by a primary care physician. As part of a PPO, patients have more flexibility and are permitted to receive treatment from any provider they want. Additionally, patients are not required to get a referral for treatment from a specialist, including rehab for addiction.
- What is medical necessity?
Medical necessity is a set of guidelines established by insurance companies to determine the type and length of care they’re willing to cover. Many health insurance companies require a specialist to assess a patient’s condition before they will agree to pay for drug treatment.
- What is typically covered by insurance?
Every health insurance plan is different. Some are very comprehensive and will cover several months of residential treatment while others require a co-pay for limited treatment. Depending on whether you have an HMO or PPO, you may also be limited on which rehab center you can seek treatment from. Services that are typically covered in full or in part include drug detox, outpatient and/or inpatient treatment and counseling.
- Why do I need an assessment?
An assessment indicates the severity of your condition and will play a role in securing coverage from your insurance company. Some health insurance companies require patients undergo an assessment to help determine if you meet medical necessity requirements.
- What is a single-case agreement?
A single case agreement (SCA) is a one-time agreement between a healthcare provider and a health plan, payor or third party administrator and is typically negotiated at the time of care. If a drug treatment center does not take your insurance, they may obtain an SCA with your provider to cover the full or partial cost of your treatment.
- What if I don’t have insurance?
There are several options for patients who do not have health insurance. You can speak with the treatment center about paying out of pocket at full cost or paying a sliding-scale fee, which is essentially a discount based on your financial status. You can also talk about setting up a payment plan. Many drug treatment facilities offer financing options.
- Can a treatment center help me access my health benefits?
While it would be helpful for you to fully review your health benefits before going to treatment, once in treatment a counselor will contact your insurance company to parse out the financial details and recommended treatment plan.