How to Get Your Health Insurance Provider to Pay for Substance Abuse Treatment
by Michaela Kajiwara
Thanks to the Patient Protection and Affordable Care Act of 2010 and the Mental Health Parity and Addiction Equity Act of 2008, health insurance providers are now required to cover a level of treatment for substance abuse disorders and other mental and behavioral disorders that’s equivalent to the level of treatment they offer for physical conditions, including surgery and general medical care. So if you have a substance abuse disorder, your insurance provider should be willing to cover some form of treatment for it.
That doesn’t mean, however, that you’ll be able to go away for an extended stay at an inpatient rehab facility. In order to get your insurance company to pay for substance abuse treatment, you’ll need to prove that it’s medically necessary. You’ll need to understand what medical necessity is and how to prove it to your insurance company. Know what your policy covers, what your rights are, what your treatment options are, and how to get your insurance provider to subsidize the level of care you need.
What Is Medical Necessity?
In order to use insurance to pay for drug rehab in Arizona or any other state, it’s important to establish that the treatment you’re requesting is medically necessary. In order to establish medical necessity, you’ll need to establish that:
- The services are required to diagnose or treat your substance abuse disorder
- The treatment is appropriate and proven to be effective
- The treatment is not just convenient for you or your doctor, but necessary for your recovery
Your insurance company may also want proof that the treatment you’re requesting is not more expensive than other treatments that could produce a similar result.
If you’ve never been through substance abuse treatment before, your insurance provider may want you to try an outpatient program instead of paying for a residential facility. You’ll need to prove that you’re able to participate fully and that you’re willing to work toward your own recovery.
However, if you have an underlying medical condition or mental illness that complicates your treatment needs, or need a more serious level of care to manage your withdrawal symptoms, your provider may want you to go to a residential facility. Reasons why you may be deemed in need of residential treatment include:
- You are a threat to yourself or others
- You have medical problems that could make it hard to adhere to an outpatient program
- Your addiction is causing problems with your health, home life, social life, or professional life
- You have already been through outpatient treatment without success
- Your living situation could hamper recovery
- Your condition could worsen without residential care
Know Your Policy and Your Rights
Before you put in a claim for substance abuse treatment, know what’s covered under your policy. Make sure the facility accepts your insurance, and check on in-network and out-of-network benefits. If your provider denies your claim, you’re not out of luck — you can appeal.
If you need help, ask your primary care doctor. A friend or loved one can also help you navigate the insurance claims process. It’s usually best that you not try to wrangle with the insurance company alone, especially when you’restruggling with a substance abuse disorder.
Learn About Your Treatment Options
Your treatment options will vary depending on what your policy covers, but not all treatments are the same. Some are more effective than others. For many people, outpatient treatment in the home environment can be even more effective than inpatient care — most addiction relapse triggers are found in the home and throughout the course of normal daily life, so outpatient treatment is the best way to learn how to cope with them.
However, depending on your state of health and the severity of your condition, you may need inpatient care. Remember to find out whether you need any authorizations, referrals, or pre-certifications.
Factor in Underlying Conditions
Underlying medical conditions like high blood pressure, chronic pain, or heart disease can complicate your treatment. Make sure that your health care team and insurance provider factor in management for these conditions. Underlying conditions may mean you need a more serious level of care.
Keep Detailed Written Records
Prior to and during your substance abuse treatment, write down the dates and pertinent details of any interaction you have with your insurance provider. Also record the names, titles, and other details of any insurance representatives you work with. Obtain an itemized list of charges from your treatment facility and a copy of the authorization letter from your insurance provider. You’ll also need a list of diagnosis codes from your doctor. These records will be invaluable should you run into an insurance snag later on.
While your health insurance provider should be willing to pay for some form of substance abuse treatment, getting your claim approved may be easier said than done. Learn as much as you can about your treatment options and hold out for the level of treatment you need. With diligence and good record-keeping, getting insurance coverage for the help you need will be much easier.
About the Author
Michaela is an avid interior design student as well as an aspiring journalist. When not scouring magazines and the internet for better and more affordable design ideas, she can be found in front of her computer busily cooking up ideas for her future novels.