According to the 2019 National Survey on Drug Use and Health, more than 21 million Americans needed treatment for substance abuse in a specialty facility but almost 19 million of those did not receive it that year.1
These numbers are similar to those of previous years, showing sadly that each year, only a fraction of those who need treatment actually get it.
People’s reasons for not getting the treatment they need vary. Some may worry about the stigma of asking for help; others may have tried before and relapsed and fear that another rehab stay won’t work. Others may fear the cost of treatment. However, fears about payment should never stop a person from trying to access lifesaving care.
Health insurance makes it possible to find treatment, but it is important to understand your policy and your options. The Affordable Care Act made mental health treatment an essential health benefit;2 however, the degree to which you’ll have coverage and where your treatment will be covered will depend on the specific details of your policy.
How Laws Are Improving Coverage
The Affordable Care Act (ACA), passed in March 2010, changed the health insurance landscape in America.
All ACA-compliant plans must provide coverage for:3
- Behavioral health care, including counseling and psychotherapy.
- Inpatient behavioral health services.
- Addiction treatment.
Another federal law that provides protections for those seeking treatment for mental health disorders is the Mental Health Parity and Addiction Equity Act (MHPAEA). The MHPAEA requires that a group health insurance plan must provide the same level of coverage for the treatment of substance use disorders and mental health disorders that they do for medical and surgical benefits.
Your level of coverage for mental/behavioral health services will depend on your state and the specific health plan that you choose. For this reason, it is critical for every insured person to have a copy of the summary plan description (SPD). The SPD is required to accurately lay out the plans benefits and coverage. If you have questions about your plan’s mental health benefits, you can start with the SPD and contact your insurance provider (via the number on your card) for additional questions.
For a quick insurance benefits verification check, you can fill out our quick and easy form now.
What Types of Services Are Covered?
Each rehab center provides a different array of services, and the insurances they accept will vary. Some will be in-network with certain providers but accept others on an out-of-network basis. Always be sure to ask a rehab center upfront which insurance companies they are in-network with. The facility may tell you they “take most insurances” but that may not mean they are in-network with them. You may be responsible for a much greater portion of the cost when you choose an out-of-network treatment facility.
Keep in mind that your insurance will likely only want to pay for services they deem necessary. This might make it harder for you to get coverage for alternative therapies or for luxury programs. It’s always a good idea to ask any questions about coverage ahead of time so you’re not surprised when you receive the bill after-the-fact.
It’s always a good idea to ask any questions about coverage ahead of time so you’re not surprised when you receive the bill after-the-fact.
If you do choose an out-of-network facility or you end up having to pay most or all of the costs on your own, the facility may be able to work with you to ease the burden of the costs. Some facilities will offer loans or financing to make it easier to get into treatment now and pay off the cost over time. Others may have scholarships or sliding scales (adjusted costs based on income) to make treatment affordable for those in need.
As you look around for a quality treatment program, feel free to ask questions of staff about insurance. An insurance coordinator at a drug rehab center can help incoming clients and family members understand how their insurance coverage works, including what services will be covered and at what percentage. However, while an insurance coordinator can provide valuable help, it is still a good idea to know your rights, as an insured person, and to understand how the claims process and appeals process works (should a claim be denied).
Desert Hope Treatment Center staff know the importance of getting the treatment that you need for yourself or a loved one. We are always willing to work with you and go over any questions you have about your insurance when you call us at 702-848-6223.
Coverage for Veterans
Veterans may be able to get care either with the VA or through community providers through the Community Care Program. The Community Care Program allows vets to access care in community programs when the VA is unable to provide the necessary care.
TriWest Healthcare Alliance administers the Community Care Program. If you have TriWest authorization, you may be able to receive treatment with Desert Hope in our specialized veterans’ program, Salute to Recovery.
Our Salute to Recovery program is a unique treatment track geared toward treating the unique needs of veterans and first responders whose lives have become unmanageable due to substance use and co-occurring mental health disorders. In our program, veterans are treated as a group. They live together in the same quarters and form a unique group that understands each other and who can support each other during and after recovery. If you’re a veteran looking for treatment or you love a veteran who needs help, let us discuss with you whether you’re covered for treatment in our program.
How Rehab Bills Get Paid
The following is a medical billing overview that sheds light on how rehab services get paid.4
- The drug rehab provides one or more treatment services and the internal billing department assigns the correct codes to the service. The codes are standardized, and the process must comply with state and federal laws.
- The drug rehab’s billing department then forwards a bill of services to the health insurance company.
- The insurance company reviews the claims included on the bill of services and determines which, if any, treatment services it will pay for.
- After a claim is reviewed, the insurance company will provide both the rehab center and the insured with an explanation of benefits (EOB). The EOB will include important information, such as the dates of service, treatment services claimed, charges, the dollar amount of any patient financial responsibility (e.g., a copay), and any amount that the rehab is being paid on the claims. The insurer will then send a payment for any covered charges to the treatment provider.
Understanding the Appeals Process
If a health insurance company refuses a claim for rehab services, the insured has a right to file an appeal. The insurance company will provide information to the insured on how to file an appeal.
It can help to know some helpful tips when a claim for a rehab service has been denied.5
- Review the EOB to understand why the claim was denied. The insurance company will have listed codes that reflect the reason for the denial. The EOB should include a key for the codes that will help you understand the reason for the denial. If it is still not clear, you have the right to contact the health insurance company and ask a representative to explain it in plain terms.
- If it appears that a simple error is the reason for the denial, ask the rehab center to fix the error and resubmit the claim to the insurance company.
- Review insurance company documents, such as the SPD, medical policy bulletin, or medical guidelines. The health insurance company is required by law to provide the insured with an SPD. These documents can help the insured to formulate an argument as to why the claim should be covered.
- If the claim was denied for a substantive reason, you’ll need evidence to prove why the claim should be covered. For example, you and your treatment provider may have to prove that your care was necessary. Keep all your medical/treatment documentation, as it could prove useful in this case.
- The last step in the filing process is to submit the paperwork. It is usually advisable to use the insurance company’s standard appeals form, so it’s a good idea to get one as early as possible.
- It is critical to stay on top of the process. Follow up with the insurance company regularly until a decision is made on the appeal.
- If the appeal is denied, ask the insurance company how to file a request for an external review. During an external review, a third party evaluates the claim and the appeal. An external review helps to remove any bias, unfair practice, or errors that may have occurred during the insurance company’s review of the appeal.
One of the best pieces of advice for working with an insurance company is to view the process as collaborative rather than adversarial. An insured person and an insurance company have a contractual relationship, so ultimately, the terms of the contract and their interpretations will govern the process. An insurance coordinator at a rehab center can help to set an insured’s expectations, so there are no surprises.
Keep in mind that rehab centers repeatedly bill for the same types of services, and they tend to know if those services are covered. You don’t have to navigate the insurance coverage process by yourself; the rehab center and insurance company can help.
- Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.
- Healthcare.gov. (n.d.). Essential Health Benefits.
- Healthcare.gov. (n.d.). Mental health & substance abuse coverage.
- Medical Billing and Coding Online. (n.d.). Course 5: Medical Billing Insurance Claims Process.
- Fitch, A. (2014). Tips for Appealing a Denied Health Insurance Claim.