How Do Insurance Providers Handle Addiction Treatment Costs?

There’s no doubt that medical treatment in the United States is expensive, especially when it comes to inpatient addiction treatment.

That notion is especially troubling when coupled with the fact that nearly 21 million Americans needed treatment for substance abuse or addiction in 2018, according to the National Survey on Drug Use and Health.

Even more troubling, those numbers are similar to numbers in other years. Sadly, only a small fraction of those needing addiction treatment actually receive it.

Reasons for not receiving treatment vary. Some people deny that they have problems with drugs or alcohol, while others claim that they cannot afford treatment.

Other people who have problems with alcohol or drugs may fear that there are stigmas associated with needing addiction treatment. They worry about how their coworkers, family, friends, and community will view them, and if they’ll treat them differently.

How Do Insurance Providers Handle Addiction Treatment Costs?

Of all these reasons, the cost of treatment shouldn’t be a barrier to effective addiction assistance. That’s why health insurance is important, since it may be the key to receiving the help you need.

Yet, that still leaves many unanswered questions. Even with insurance, you may be limited to specific rehab facilities and may only be covered to a certain extent. So, how do health insurance providers deal with addiction services and treatment?

Know Your Rights

Addiction treatment coverage expanded under 2010’s Patient Protection and Affordable Care Act (also known as the Affordable Care Act, the ACA, and Obamacare). Under the provisions of this law, health insurance providers must cover certain aspects of medical treatment.

Such includes behavioral health, including both psychotherapy and counseling. On that list of required coverage is also addiction treatment and inpatient services relating to behavioral health. In essence, your health insurance provider must, by law, cover costs associated with addiction treatment and related services.

Federal law also allows for other treatment provisions. The Mental Health Parity and Addiction Equity Act (MHPAEA) determines how much coverage your health insurance provider must offer for mental health services, including those relating to behavioral health and addiction treatment. Under the act, health insurance providers must provide the same amount of coverage for behavioral health treatment as they do for medical/surgical procedures.

Even then, your overall health insurance coverage options will vary depending on the plan you have and the place you live. It’s best to check your summary plan description (SPD) in order to better understand your coverage. Each SPD must clearly explain your coverage options, including services it covers and how much the insurance will pay in each instance.

Which Services are Covered?

Even though your insurance provider must cover treatment for behavioral health and addiction, it can still limit your ability to receive care. In some cases, your provider may only offer coverage for a predetermined list of rehabilitation centers in your area or facilities that are in different areas.

In other cases, an insurance provider might disagree with you about what it deems a necessary procedure versus what it deems an optional one. This is an important distinction because services deemed optional are typically not covered by insurance.

Because of these distinctions, it’s important to speak with an agent from your insurance provider to discuss what is and what isn’t covered. At the same time, if you’ve found an addiction treatment center, speak with its representative about coverage. Ask the representative which treatment options are recommended and essential and which ones are optional.

In some cases, a health care provider such as a doctor might write a letter to your health care insurance provider to establish what is necessary for your treatment regime.

What About Private Health Care Insurance?

Along with federally provided insurance, private insurance companies must also abide by similar rules. Many companies such as UnitedHealthcare, Cigna, Aetna, and Blue Cross Blue Shield all offer varying coverage options as well. Keep in mind these plans will vary in the amounts they offer, what they consider essential, and other aspects.

Putting It All Together

In essence, your health care insurance provider is mandated by law to cover your addiction treatment costs, to an extent. Consider sitting down with the drug or alcohol treatment center staff to discuss insurance and billing procedures.

Often, treatment centers have staff members who have experience working with different types of insurance plans. They understand how to navigate insurance systems that can be complicated at times, especially for people unaccustomed to working with billing and medical coverage.

You should also bring your provider’s summary plan to help your treatment professionals determine your treatment plan and financial costs. In some cases, it may make sense to enroll in a new health insurance policy before beginning a treatment program.