My Insurance Will Cover Addiction Treatment… Not So Fast!

Health insurance is a hot button issue and it isn’t likely to change anytime soon. Whatever happens in public and private insurance coverage, it’s likely that it will remain a twisted and confusing path to getting your coverage for addiction services. It’s important for you to be an educated consumer while searching out your options for substance use help.

Here are some quick tips to get you started if you are interested in using your health insurance for addiction services for you or a loved one:

• Always get a complete original copy of your health insurance policy and consult it frequently. You need to know the exact language of your policy in order to determine your program options.

• Don’t assume that words in your policy have only their standard English definitions. You should consult the definitions page in your policy whenever possible. Often insurers will place criteria in the definitions that can affect whether your program or service of choice will be covered at all and under what conditions.

• Medical detoxification and substance use programs are not the same thing and they are covered differently under your insurance. Even when you receive medical detox services and your substance use program at the same time in the same facility, these services are covered separately. Medical detox services are a medical service and covered as such under your health insurance. Substance program services are more akin to mental health services and will be subject to different criteria. Be very careful to understand clearly from both your insurance company and your addiction provider what services are covered, for how long, and to what extent you have coverage for these services. It’s equally important to be aware of what isn’t covered so you don’t have unexpected added charges to your final bill.

• Appeals are becoming more and more a part of the standard processing of health insurance coverage, especially for substance use help. Estimates are that at least 25% of claims are denied on the first try and, for substance use and mental health claims, the numbers may be as high as 60%. A denial of coverage is a starting point, not an end, but you have to be willing to mount your case, meet all deadlines, and do some homework. Be prepared to appeal whether your coverage is denied in whole or part. Keep a record of all your phone calls, letters, and communications between you, the insurance company, your substance program provider, and anyone else involved, such as your primary health care provider, your employer, EAP representative, etc. At a minimum, you’ll need to note dates, times, names, and titles of everyone you speak with and a brief summary of your conversation.

These few tips will get you started on how to access your health insurance to cover help for substance use for yourself or a loved one. If you’d like to learn more about getting insurance to cover your program, we offer a free e-book that explains in depth more ways to help you navigate health insurance as well as the pros and cons of choosing insurance or self-pay options when you’re seeking substance use help.