It can be complicated, but understanding your rights and options can help.
Navigating the insurance process for addiction treatment can become a nightmare if you are stuck with large or unexpected bills. Instead of “getting the care you need and then figuring out how to pay for it” we’re here to help you “get the care you need and have insurance help pay for it.”
Insurance coverage for addiction treatment varies by your plan and where you live. It’s complicated, but it’s doable. Here are some steps to follow:
1. Take a deep breath.
2. Review your insurance plan benefits and coverage.
You can find most of these online through your insurance portal’s website. They are called “certificates of coverage.” If you can’t find it, call your insurance provider to clarify. The phone number can be found on the back of your insurance card.
3. Find quality evidence-based care.
Use the level of care, or treatment setting, recommended by the Addiction Treatment Needs Assessment, and/or by your healthcare provider, to narrow down the list of options and find high quality evidence-based treatment that is covered under your insurance plan.
4. Understand your rights under the law.
The Mental Health Parity and Addiction Equity Act requires private insurers to cover SUD/MH benefits at an equal cost to medical/surgical benefits. The Affordable Care Act requires a Medicaid plan to cover substance use disorders and mental health disorders as “essential health benefits.”
5. Keep any documentation of communication with your insurance plan.
This includes explanation of benefits, phone calls, emails, bills, and/or denial letters.
6. If you are denied coverage for care, appeal. If you are denied again, appeal again.
Your insurance company is required to provide you with the standards they used to deny care. They may say it was deemed “not medically necessary,” in which case, ask the medical provider to provide information on medical necessity. If you have been denied and are unclear on your rights, find out about common violations.
7. If you receive a surprise bill for care, follow these steps to negotiate your bill.
If you or your loved one are not insured, there are programs that offer payment assistance or scholarships for treatment. Be mindful of programs or facilities that offer “free” stays for treatment. Facilities that utilize these tactics are typically not quality programs and may be fraudulent. To learn more about quality treatment that is based on science, visit ATLAS.
Check if you’re eligible for Medicaid.
Under the Affordable Care Act (ACA), behavioral health services became mandatory for public insurance (Medicaid) to cover in every state. As an “essential health” benefit, addiction treatment cannot be denied to a patient under public insurance.
If you are below a certain household income threshold, you may qualify for Medicaid. If you or a loved one are pregnant and/or are below 19 years of age, you automatically qualify for Medicaid. See if you’re eligible for Medicaid in your state.
Look into community health centers and state-run options.
States have federally funded government treatment centers that may be an option. A hospital or state-run medical facility may be another option. Community health centers are nonprofit health providers that may be able to assist with treatment costs or offer payment on a sliding scale. Find one in your area.
Ask about payment assistance.
If your provider is recommending a level of care that requires an in-person stay at a treatment facility, see if they accept Medicaid. If they do not, speak to them about a sliding scale based on income, and/or a payment plan or scholarship.
Get expert guidance about what treatment might be right for you or a loved one.
Search for treatment providers, narrow the list, and ask the right questions to make your choice.
Here are some tips for talking to your employer, friends, and family about treatment.