There are a number of laws and regulations surrounding support, coverage and funding for behavioral health disorders, and addiction treatment specifically.
Most insurance plans now days do have benefits for addiction treatment, though there is no uniform level of coverage. It is only mandated that it should be comparable to benefits for other major medical healthcare needs.
However, since every carrier and plan is different, even groups from within the same employer sometimes, there is no real way of knowing how much your policy will cover until you find a treatment program you like and have them verify your benefits and discuss the coverage with you for their center. There are multiple things that can affect this, and here are a few explanations that might help:
Deductible – This is the amount you’re required to pay before your policy will issue any payment for services provided. We have seen deductibles range from $50 all the way to more than $15,000.
Co-pay or Co-insurance – This means the amount you are responsible for after the deductible is met. Usually the plan will cover between 50% and 80% of the allowable charges.
Allowed Amount – This usually refers to that plans maximum recognized fee for a particular service, especially when dealing with an out of network provider. For example, a facility may charge $2,500 per day for residential treatment, but your plan’s allowed amount may be half that. Your co-insurance is usually applied to the allowed amount, not the billable rate initially charged. For providers that are in network, the billable rates will equal to the negotiated allowed amounts.
Out of Pocket Maximum – Most plans have an out of pocket maximum for coverage. Often this is between $10,000 and $20,000 per person per calendar year. We have seen upwards of $30,000 occasionally. This means that the insurance company expects you to cover the amount up to your OOP Max, at which point then will then usually cover approved services at 100% of their allowed amount.
Covered Days – Insurance companies have the ultimate say so when it comes to what services they will pay for, and they usually require some form of pre-certification or at least pre-authorization to determine medical necessity. This is how they cut down on the number of days for the higher levels of care and try to get people into a form of treatment that is not as expensive for them. Let’s say that someone is pre-authorized for 10 days of residential treatment, and then denied further coverage and forced to step down to PHP (day treatment) for another 10 days, and then forced to step down into intensive outpatient for 30 days. Each time the number of pre-approved days are up, the treatment center’s utilization review department (or their third party billing company) must present clinical documentation requesting more days at a particular level.
HMO Plan – This type of policy has benefits for providers that are are in network only. In some rare occasions, someone could get a single case agreement for a facility that is out of network, but there are many quality treatment programs that are in network now that it shouldn’t be a problem finding one. The exception is if you are trying to stay only in a specific area, or potentially if there isn’t an outpatient provider close enough to you. Some providers will offer self pay discounts to those with no insurance or with HMO plans that don’t cove their programs.
PPO Plan – This type of policy means that you are allowed to go to the provider of your choice, whether they are in network with your insurance carrier or not. Insurance companies try to dissuade patients from going to out of network providers, because it usually costs them a little more, by providing incentives to stay in network, such as lower deductibles and lower co-pays. However, if you find a program that you really want to attend, don’t let the fact that it is out of network be the deciding factor, as they may be able to work with you.
