Detoxification and rehabilitation are the two treatment categories of substance abuse. Detoxification is short term medical treatment to manage withdrawal symptoms and rehabilitation is longer term counseling and classes to help the individual to remain sober. There are five basic questions to ask in determining substance abuse benefits through your health insurance.
1. Do I have substance abuse health insurance benefits? Under current law companies providing group health insurance are only required to cover treatment for alcoholism not for drug abuse. However, most large group plans have substance abuse treatment benefits. A basic policy will cover outpatient treatment but will not cover residential rehabilitation care. Some plans offer “riders”, or supplemental options- for an additional premium amount- to augment a basic policy. Check with your health insurance company.
2. What is my deductible and has it been met? Most health insurance plans have a yearly deductible that must be met before benefits are paid out. These can range anywhere from $100 to $5000. Under the new healthcare reform, there can no longer be separate deductibles for substance abuse and medical/surgical services. Check your plans schedule of benefits to determine the amount of your deductible and contact your insurance company to see how much of your deductible has been met.
3. What is the coverage amount per visit? Each health insurance plan will have different coinsurance or co-pay amounts for outpatient rehabilitation. You will either pay coinsurance- usually 80/20 – or you will have a co-pay per visit. Many plans limited the number of outpatient rehab visits to 20 per year but healthcare reform eliminated those benefit limits. The elimination of these benefit limits allows greater access to needed treatment.
4. Is approval required from my primary care physician? Many health insurance companies require you to see your primary care physician to get a referral for substance abuse rehab unless it is court ordered. Authorization is usually required before rehab can begin. Many healthcare plans required members to complete a rehab program before payment would be made on the charges. If you did not complete the program then you did not receive the benefits and were personally responsible for the charges. Healthcare reform does not allow this anymore. Charges are paid by the insurance companies during treatment.
5. What is the reimbursement policy for out-of-network providers? A majority of health insurance companies require you to see in-network providers and do not provide any benefits if you go out-of-network. This is the same for any type of medical treatment, as well. Health insurance companies try to keep costs down by having its members utilize their network.
Healthcare reform has changed many aspects of substance abuse rehabilitation by bringing it into the realm of medical care. Insurers who cover substance abuse treatment must do so at the same level of benefit they provide for other medical conditions. This should increase the number of people seeking the help they need.