It can be difficult to navigate the complexities of insurance coverage, especially during a crisis like drug or alcohol addiction. Sadie Sanzotta is the National Manager of the Benefits Verification Department for Elements Behavioral Health, a nationwide network of addiction treatment centers. She has worked in the insurance benefits field for over nine years and offers some insight into how to get insurance to pay for drug rehab.
A PPO insurance plan offers more provider options and usually allows you to travel outside of your home state for treatment. “PPO coverage is the best type of insurance coverage,” says Sadie. “I recommend going with a PPO plan if you have a choice, can afford it, and anticipate needing residential addiction treatment.”
An HMO or EPO (Exclusive Provider Organization) insurance plan usually covers a smaller number of treatment providers than a PPO plan and often requires you to attend treatment within your state. Some HMOs don’t require you to stay in state, but do require you to use a preferred network provider, so your options are more limited.
Make sure your insurance plan includes mental health and substance abuse coverage. Sometimes this is an optional component of insurance plans. “If you think that you or one of your dependents will be entering drug rehab, be sure to opt into that coverage when you sign up for benefits during the open enrollment period,” says Sadie.
Insurance companies require you to prove medical necessity in order to receive inpatient treatment for substance use disorders and mental health conditions. This means you must have a clinical need for treatment based on scientifically backed standards of care that deem drug rehab justifiable and appropriate. The process typically involves submitting a certificate of medical necessity to your insurance company, which must be completed by an examining physician or other qualified healthcare provider.
Check that your insurance plan covers a residential level of care. Even if your insurance is in network with a drug or alcohol rehab facility, you must make sure they cover residential treatment in order to receive benefits for inpatient drug rehab.
Determine if your insurance permits you to travel out of state for treatment. The best drug rehabs might not be located in your home state, so ensuring that you’ll be able to travel for treatment if necessary is important. Many people find that getting some space and distance from their home environment helps them focus more on treatment. “People who attend our drug rehabs are from all over the country, so we always make sure clients have that benefits component when we consider treatment recommendations,” says Sadie.
The good news is that even if an individual didn’t foresee going to drug rehab when electing insurance coverage during open enrollment, in most of the cases Sadie sees, the necessary options are in place. She estimates that only about 10% of the calls her team receives are instances where the individual’s insurance requires they get treated in an acute care setting instead of a specialized residential drug rehab facility. “For the most part we see that people do indeed have that mental health and substance abuse component they need to attend rehab,” says Sadie.
The quickest and simplest way to determine what type of insurance you have is to call the treatment center to see if they’ll work directly with your insurance company to verify your coverage and any out-of-pocket costs. At Elements Behavioral Health, Sadie oversees a team that serves as liaisons between insurance companies and clients. When an individual or their loved one calls to inquire about how to get insurance to pay for drug rehab, they do all the legwork to determine their insurance benefits.
Sadie explains that determining insurance coverage for drug rehab involves the following:
Phone consultation – After an initial phone consultation with a recovery specialist, callers receive a list of the best treatment options based on their clinical needs and preferences.
Insurance benefits check – A team member calls the insurance company and asks their representatives a series of questions to determine the type of insurance and the specifics of the person’s benefits.
Cost estimate – The team member explains any out-of-pocket costs based on the estimated insurance contribution and deductible.
Pre-approval – If the insurance requires pre-approval, the team helps with authorization prior to the client entering treatment.
Medical necessity – All clients go through a pre-admissions assessment which assesses the likelihood of medical necessity. The medical and clinical exams needed to fulfill medical necessity take place by the clinical staff at the drug rehab facility.
If your insurance doesn’t have a substance abuse residential component, consider these possibilities:
Outpatient Treatment – People who don’t require a higher level of care may participate in outpatient programs to address the underlying reasons behind their addiction and acquire healthy coping skills to help them stay sober.
Self-Pay – Think of drug rehab as an investment in your future. If you’re able to make financial sacrifices to pay for addiction treatment, sobriety will be well worth it. Not only is life more fulfilling in recovery, in the long run you’ll be saving money you’d be spending on a lifetime of drugs and alcohol and potentially DUIs, arrests, injuries and health issues. There’s also the financial hardship of possibly losing your job to addiction. Most importantly, drug rehab can help you prevent doing more damage to your relationships and stop putting your life at risk. If you’re still deciding which treatment options are right for you, learn more about choosing your path to recovery here.
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