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As part of the Affordable Care Act
drug rehab will be required beginning in 2014 as part of essential benefits. This should help increase benefits for those who don’t have coverage and for those who are “under-covered.”
Even when you have coverage, you still need to pay close attention to what that coverage is and how the insurer will manage your case. Whether you have Blue Cross and Blue Shield, Aetna, Cigna, United Health Care, Tufts, Kaiser, Humana, Northwest Medicare, Medicaid, or another plan, there are 10 questions you should ask your plan’s customer service representative to help make sure you get the best, most affordable care. There are different rates for Detox Centers, Luxury Drug Rehab Centers and Residential Treatment Centers.
Ten questions you should ask your plan’s customer service representative
1. Does my plan provide coverage for treatment of drug abuse: It’s important to understand the federal Parity Act, but most people don’t know whether an employer is a self-funded group plan, or how their state laws handle benefits for substance abuse treatment. Your plan’s customer service representative will be able to tell you exactly what your benefits are. Sometimes benefits for drug rehab are handled by a “managed behavioral health organization (MBHO).” If that’s the case, your insurer should let you know the name of the company and how to contact them. Then you will deal with the MBHO.
2. Do I need a referral from my doctor: You’ll want to find this out before drug treatment, since in some cases, benefits can be reduced or denied if you don’t get required referrals. If you got emergency treatment without time for a required referral, call your insurer as soon as possible and explain, and then follow their instructions.
3. Is my diagnosis covered: Your health insurer will consider whether they believe your condition is “medically necessary.” Some plans may not cover repeat care if you didn’t follow through with your last course of treatment. Other times, they may cover your care, but not to the extent you would like. For instance, they may say that for your diagnosis, only outpatient treatment is covered. In addition, your insurer will consider if there is any reason that your treatment would fall under a general exclusion of the plan. This would be the case if you have coverage through your employer, but your addiction is caused by active service in the military. Another exclusion may apply if your treatment was court-ordered.
4. What type of plan do I have: Some common plan types include:
Preferred provider organizations (PPO) – With a PPO plan, you can choose a covered provider (as long as they meet the plan’s definition of a covered provider). However, you get a greater benefit if you go to “in-network” providers, rather than “out-of-network” providers.
Managed care plan – With a managed care plan, you must go to an in-network provider to receive coverage.
Consumer-driven health plan – These plans are usually a PPO hybrid, and have very large deductibles (thousands of dollars). Usually once the deductible is met, all covered services are paid at 100 percent.
5. Is there a difference in coverage between in-network and out-of-network care and if so, what is it: It’s common for plans to pay a higher benefit for in-network care. For example, a plan may pay, say, 100 percent of the covered cost for an in-network provider, but perhaps only 70 percent of the cost of an out-of-network provider. So it’s important to know what you’re getting into if you choose a non-network provider.
6. Is there a deductible: The deductible is the yearly amount you must pay before the plan will start paying benefits. In some instances, the deductible is waived, like for preventive care or sometimes for inpatient care. Under some plans, any amount applied toward your deductible in the last three months of the calendar year is carried over to help meet your deductible during the next year.
7. Will there be copayments: Copayments are like mini-deductibles. They apply to individual services, like office visits, prescription drugs, and others, and they usually do not apply toward your deductible. It’s important to understand how much your copayments are and what they apply to. If you will be having outpatient care, you may have to pay a copayment for each treatment day, and copayments are usually due on the date of service.
8. What is my out-of-pocket (coinsurance) limit: If you pay a percentage toward your medical services, like 30 percent after 70 percent coverage or the 20 percent after 80 percent coverage, those amounts you pay go toward your yearly out-of-pocket limit. Once that limit is met, your remaining covered health expenses for the year are paid at 100 percent. If your rehabilitation is covered, your insurer will pay the provider directly, but you will be billed for out-of-pocket expenses.
9. Are there any restrictions on where I can get help: Besides considering “in-network” providers, your plan will likely only cover certain drug rehab facilities. You’ll want to ensure you find out up front, so that you can choose the most effective, and affordable drug rehab center.
10. How will my care be reviewed while I’m in treatment and how will any reviews impact my coverage and treatment? If you will be having inpatient or residential treatment, it’s important to know that your care will be monitored, likely by the insurer’s nurse case manager. As you make progress, your insurer will want to be certain that the level of your addiction treatment matches the severity of your condition. And they will decide this based on “concurrent” and other reviews. This list was provided by www.drugrehab.org.
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