Many addicts never seek the treatment they need for their addiction, even when they feel like they want to recover. Inaccessibility of treatment is a huge problem in the United States, where the cheapest inpatient treatment has costs of $10,000 per month. Those costs can soar up to $80,000 if you go to a luxury facility. Detox programs tend to last for a week or two rather than months, but the medical costs can be exorbitant. You deserve to get the treatment you need, but you might have to deal with some bureaucracy first. These are the step-by-step guidelines and questions to ask your insurance company before going to an addiction detox center.
Insurance companies will often be picky with the services they’re willing to cover. Sometimes you won’t be able to have inpatient treatment covered until you’ve done intensive outpatient. Sometimes certain offered detox programs will be covered, and others won’t. Sometimes you’ll be covered to a point, but you’ll be expected to pay the rest of the cost out-of-pocket. Knowing what to ask your insurance company will get you the answers you need to make treatment decisions.
How to Approach Your Insurance Company About Treatment Coverage
No matter what kind of insurance you have, the policies regarding medical treatment will inevitably be complex. Your provider will calculate the amount they cover based on your policy and deductible, which can lead to wildly different amounts. Also, different treatment aspects will often have different coverage rules applied to them. You might pay differently for your week-long inpatient detoxification than for outpatient therapy services, and still different for a full inpatient program at a rehab facility.
Pre-Treatment Contact of Your Insurance Company
Your first step will be to call your insurance company’s Member Services department. The representative will be able to give you detailed information about options for addiction treatment. Make sure that your membership identification number and insurance card are both ready. Type or write notes as you talk, including the representative’s name and the date the call occurred. If you need clarification or have questions, don’t hesitate to ask.
Questions to Ask and Information to Get
Find out what type of insurance plan you have. The main plans are:
- EPO – Your insurance company only covers health services if they come from providers in the insurance company’s network, excluding emergency cases.
- HMO – Your insurance company gives coverage to providers who contract with or work for the HMO.
- POS – A plan where you can use out-of-network providers, but you pay less for in-network providers. You also need a referral given by your primary care physician when you need to see specialists.
- PPO – A plan where you can use out-of-network providers, but you pay less for in-network providers. You don’t need a referral to see specialists, but non-referral visits cost more.
- Medicaid – Government-supplemented plans that are variable depending on your state of residence.
- Medicare – Varying government-supplemented plans with different coverage options depending on the specific type of plan you have.
Ask your insurance provider to give you details about your coverage. These include the length of time you can stay, the contracted providers in your network, the available clinical care levels, and the potential stages of treatment.
If you’re only considering an intensive detox program at a detox center, be clear about that. These programs are usually about one or two weeks long as opposed to the several month-long follow-up rehab programs. Some people undergo medically supervised detox and then pursue outpatient treatment rather than inpatient rehab.
Explain the search radius of locations you’re willing to explore. Ask if your insurance provider can give you information about covered options within this radius.
Ask about the insurance requirements for admission. Do you need a referral, pre-approval, or prior authorization to have your detox stay covered?
Ask about the maximum out-of-pocket expense you might have to pay for addiction treatment. This should include information about the specific co-pays and costs associated with your different treatment options.
You should request a copy of the provider’s criteria for the determination of “medical necessity.” Insurance companies will generally cover treatment only if medically necessary, but different policies have different definitions of medical necessities.
You should also request an emailed list of in-network treatment providers. That’s a lot easier than trying to write down all of their individual names and contact information on your note sheet.
Appealing if Coverage Is Denied
More than one-fifth of all cases appealed due to “denial of coverage” end in favor of the individual covered by the policy. A first level appeal has a low potential success rate, but subsequent appeals increase your chances of success. You can’t give up.
Before you can appeal treatment or services on higher levels, you’ll need to have a direct appeal to the insurance company denied. If you’re appealing your insurance coverage, you should make sure to preserve as much information as physically possible. This includes correspondence, names of the provider’s representatives, notes about calls, and all detailed information about your coverage. Make sure that you keep the information in one place for easy reference.
Appeal processes have a range of potential lengths. If the case is urgent or expedited, a decision is usually made within 1 to 3 days. Standard appeals take between 30 and 60 days. Internal appeals are handled by the insurance company, while external appeals are mediated by a neutral third party.
Before you file any appeals, you should find out whether your healthcare provider has engaged in a conversation with the medical director at the insurance company who handed down the denial.
Successful appeals are ones that are completed within an appropriate time frame and include comprehensive documentation of the medical and policy-related facts.
For more information about insurance coverage, financing options, and affordable treatment plans, call one of our trained counselors at 877-978-3125. We’re available 24 hours a day to help you get the treatment you need.