How Do I Find Out How Much Treatment Insurance I Have?
Many different provisions affect the rate at which health insurance covers given medical conditions. Determining the extent of addiction coverage that policies provide begins with reading the provided information thoroughly. It can be helpful to understand ways in which policies may differ.
When people purchase health insurance, they should receive documents that explain their coverage. These include Summary Plan Descriptions and Evidence of Coverage. Sometimes the information is available online. People who are covered by group health insurance offered through an employer may need to ask their employer or human resource department for a copy of the information.
The insurance industry often uses terms that are not easy for those unfamiliar with them to decipher. One provision of the recently enacted Affordable Care Act (ACA) is that policies covered by the legislation must make the information they share about coverage clear. The Healthcare.gov website notes that the ACA requires companies to provide a short, plain-language Summary of Benefits and Coverage along with a glossary of terms.
Questions to Ask When Determining Insurance Coverage
When determining coverage for addiction treatment, the following questions should be answered:
- Is addiction a covered condition? – Coverage for addiction has improved over the years with many states mandating that insurance policies sold within their borders cover the disease to some degree or at least offer optional coverage to those who desire to purchase it. A publication by the Substance Abuse and Mental Health Services Administration titled “State Mandates for Treatment for Mental Illness and Substance Use Disorders” notes that most states have addressed the issue to some extent but that great differences exist between them. They also note that coverage for substance abuse tends to be less comprehensive than coverage for mental health disorders. All policies covered by the federal Affordable Care Act (ACA) must offer coverage for certain essential benefits including addiction treatment.
- Are there limitations on what types of treatments are covered? – It is not uncommon for a policy to cover outpatient treatment, for example, but not to cover residential rehab. There also may be differences in the way detoxification is addressed. The ACA mandates that addiction coverage include counseling and psychotherapy.
- What sort of prescription coverage is included? – The National Institute on Drug Abuse notes that many patients find medications to be an important element of treatment especially when combined with behavioral therapies. They list methadone, buprenorphine, naltrexone, acamprosate and disulfiram as medications that may be helpful.
- What is the co-pay amount? – A co-pay is the amount that a policyholder pays at the time of service. Generally, co-pays are not reimbursed. At one time it was not uncommon for co-pays for addiction treatment to be higher than what was required for other medical conditions, but a series of parity laws have been enacted which mandate equal treatment in most instances.
- What is the deductible? – The deductible is the amount of money that policyholders must pay annually before insurance coverage begins. Sometimes there is a separate deductible for prescription drug coverage.
- How much is the co-insurance? – Co-insurance is the percentage of a healthcare expense not covered by the insurance company after the deductible has been met.
- Are there annual or lifetime limitations on the number of healthcare visits that will be covered? – Some policies cap the amount of visits for any given condition.
- Are there lifetime or annual financial imitations to coverage? – Sometimes insurance companies cap the amount of money they will spend or reimburse in a given year or over the course of coverage.
- What is the out-of-pocket financial limit? – Some policies cap the amount that policyholders are required to pay during the year. Certain expenses, such as the amount spent for premiums, do not generally count toward the limit.
- Will coverage rates differ depending on providers? – Health plans can generally be categorized as Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs) or Fee-for-Service plans. In PPO plans, insurance companies arrange with certain healthcare providers to offer services at a reduced cost. If policyholders receive services from providers outside of this network, they must pay a larger percentage of the fees. In an HMO plan, policyholders pay a flat fee for the ability to access participating providers. Generally they do not pay deductibles, but co-pays may apply. In Fee-for-Service plans, individuals pay for their own medical care, then submit claims for reimbursement.
- Is reassessment needed for continuing coverage? – Some policies will cover a certain amount of treatment then require that need be reassessed before covering the condition further.
- How is medical necessity determined? – Most insurance plans make reference to covering treatments that are deemed medically necessary. An important consideration not always detailed in plan information is how that will be determined. Some insurers follow guidelines such as those provided by the American Society of Addiction Medicine. Others make the determinations more subjectively.
We Can Help You Determine Your Coverage
If you are curious about the extent of your insurance coverage for addiction treatment, we can help you find the answer. The individuals who staff our toll-free helpline can determine your coverage and can answer other treatment questions you may have. The helpline is available 24 hours a day, so there is never a wrong time to call. Why not call now?