It’s important that you or your family member get the addiction treatment your healthcare provider is recommending. But this 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:
Take a deep breath.
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.
- Understand what you might be responsible for: This will likely include meeting a deductible, cost sharing, and/or co-payment. Remember, this may be different depending on the care setting for addiction treatment, such as outpatient or residential care so be sure to ask for specifics. If you aren’t sure what treatment setting is most appropriate, check out the Addiction Treatment Needs Assessment.
- Understand if you have in-network or out-of-network benefits, or both. This may limit access to specialty providers or require a referral.
- If being treated for opioid use disorder, make sure the insurance plan covers medications for addiction treatment.
- Check with your insurer if you need prior authorization for specific treatment settings, medications, or office visits that your provider recommends. Also check if there are limits or caps to these services.
Find quality evidence-based care.
Use the level of care, or treatment setting, recommended from the Addiction Treatment Needs Assessment, and/or by an independent provider, to narrow down the list of options and find quality evidence-based treatment that is covered under your insurance plan.
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 SUD and MH as “essential health benefits.”
Keep any documentation of communication with your insurance plan.
This includes explanation of benefits, phone calls, emails, bills, and/or denial letters.
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.
If you receive a surprise bill for care, follow these steps to negotiate your bill.