Insurance for substance use disorder (SUD) and/or mental health (MH) is complex. To help you navigate this system, here are some things to know, some things to do, what to do if you are denied coverage for treatment, what to do if you don’t have health insurance and some helpful definitions.

Please note: Words in italics are defined below.

WHAT TO KNOW

  • Many insurance plans do cover Mental Health/Substance Use Disorder. It’s the law. (Parity Act; Affordable Care Act)
  • Effective care for substance use disorder is provided in different treatment settings or levels of care. The appropriate level of care is determined by a medical professional, based on a comprehensive assessment. The assessment will determine the level of care that is most appropriate.
  • Inpatient treatment may include treatment in a hospital or a residential treatment facility. Outpatient treatment may be provided in a doctor’s office or clinic. There are also “intermediate” services, which include intensive outpatient (IOP) and partial hospitalization/day treatment. Ideally, the plan should cover all these levels of care, but they may need prior authorization.
  • If your plan doesn’t cover these different levels, it is important to talk to your treatment provider about the level of care that is covered by your plan that is most appropriate. If a patient is placed in a lower level of care than what is needed, his or her needs may not be addressed adequately, but placing a patient in a higher level of care than is needed means the patient may receive unnecessary care at a higher cost.
  • Depending on the type and severity of your substance use disorder and general health status, the use of medication (medication assisted treatment – MAT), psychosocial therapies, or both in combination may be necessary. Medications are an effective and, for some conditions, critical component of addiction treatment.
  • It is important to know whether the treatment provider you choose is in-network or out-of-network. Some plans will not cover payment for services from an out-of-network provider or you will have higher out-of-pocket costs for receiving care from an out-of-network provider.

WHAT TO DO

Review Your Insurance Coverage.

Look at your insurance plan’s certificate of coverage which can usually be found on your insurance carrier’s website. If you are still unsure, call your insurance carrier to clarify. You can use the phone number on the back of your insurance card. (You will also need this card for the treatment provider you choose).

Prepare a list of questions before you call your insurance carrier.

Having a list of questions will help you to focus your thoughts. Take notes and write down the name of the representative you are speaking to and the date of the call. Some questions you might ask are:

  • Does my insurance coverage include every phase of drug or alcohol rehab (detox, inpatient and aftercare)?
  • How many days are covered?
  • Is there a limitation on the number of visits?
  • Does my policy cover the different types of counseling services that are often included in substance use disorder treatment? (individual and group counseling)
  • What is my copay and/or deductible for SUD treatment?
  • Does my policy require me to use an “in-network” provider?
  • Can you provide me with some “in-network” providers close to where I live?
  • Do I have different health insurance coverage for co-occurring conditions such as bipolar disorder, depression, PTSD?
  • Do any of the services require prior authorization?

Keep track of any notices you receive from your plan.

This includes letters authorizing care, denial letter, Explanations of Benefits, phone calls, emails, as well as any bills that your receive from your provider. Keep track of the date of the communication, the name of the person you spoke to and a summary of what was discussed.

WHAT IF MY INSURANCE COMPANY DENIES COVERAGE FOR TREATMENT?

If your insurance company says that your addiction treatment is “not medically necessary”, ask your insurance company to provide the standards that were used to make that determination. They are required to provide you with this information. Be sure to appeal the decision. When filing a complaint or appeal related to a denial for MH/SUD benefits, make sure to specifically state that you believe the plan is violating federal parity law. Your plan should offer both an internal and external appeal process and you are often required to go through the internal appeal before the external appeal. You have to file appeals within certain time frames, so make sure you know how much time you have to file an appeal and file it on time. Sometimes the request may be denied because they require specific information from your doctor. Make sure your doctor provides additional information to demonstrate that the service is medically necessary.

You can also contact the Ohio Department of Insurance (ODI), Consumer Services Division at 1-800-686-1526

www.insurance.ohio.gov

Note: If you are a senior, contact OSHIIP (Ohio Senior Health Insurance Information Program) Hotline: 1-800-686-3745

WHAT IF I DON’T HAVE INSURANCE?

  • Some treatment providers offer payment plans and some offer treatment to patients regardless of their ability to pay. Some providers will also help patients to get on Medicaid.
  • Contact your local ADAMHS (Alcohol, Drug Addiction and Mental Health Services) Board for a listing of providers who can help you apply for Medicaid. If you are not eligible for Medicaid, your local County Behavioral Health Board may be able to assist with funding your treatment and recovery supports. To locate your local Board you can visit More Help by county on the Emerald Jenny Foundation website or visit: https://www.oacbha.org/mappage.php.
  • You can go to healthcare.gov to compare and purchase a health insurance plan, however there is a specific period of time for open enrollment. Outside of Open Enrollment, you can get health insurance only 2 ways:
    1. With a Special Enrollment Period. You can qualify if you lose job-based coverage, have a baby, get married, or have certain other life changes.
    2. Through Medicaid or the Children’s Health Insurance Program (CHIP).
    You can apply any time and can enroll immediately if you’re eligible.
    (Note: In some limited cases insurance companies sell private health plans outside Open Enrollment that count as a qualified health plan, however most health plans sold outside Open Enrollment don’t count as a qualified health plan).

 


DEFINITIONS

Affordable Care Act (ACA) – The Patient Protection and Affordable Care Act (PPACA), often shortened to the Affordable Care Act (ACA) or nicknamed Obamacare, is a United States federal statute enacted by the 111th U.S. Congress and signed into law by President Barack Obama on March 23, 2010. Not only did it extend coverage to millions of uninsured Americans, but it requires plans sold on the marketplaces (individual and small group plans), as well as Medicaid expansion plans, to cover substance use disorder and mental health benefits as “essential health benefits”.

Aftercare – Programs that offer structured support (generally one to two hours per week) for people who have completed treatment and want additional help to prevent relapse.

Annual Limit – A cap on the benefits your insurance company will pay in a year while you’re enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.

Assessment – A thorough substance use assessment includes a detailed inventory of the type, amount, frequency, and consequences of the patient’s substance use, their perception of their use and readiness to change, an assessment of co-occurring psychiatric disorders, a medical history, physical examination and laboratory tests, the presence of substance use disorder in the patient’s family, and review of social factors that may contribute to substance use or facilitate treatment. The assessment will determine the level of care that is most appropriate.

Certificate of coverage – When you enroll in a health insurance plan you are given a certificate of coverage. It may also be called a contract, evidence of coverage, or summary plan description (SPD). This document explains the health benefits you and your dependents have under the plan.

Coinsurance – A financial (cost-sharing) requirement imposed by a health plan whereby a patient must pay a certain percentage of the total cost of health services. For example, a 30 percent coinsurance means that if a bill for health services is $1,000, then the health plan will pay $700 and the patient must pay $300.

Copayment (or copay) – A financial (cost-sharing) requirement imposed by a health plan whereby a patient must pay a set amount when receiving health services (e.g., $25 per doctor’s visit or $100 per admission to a hospital).

Cost-sharing – The amount a patient has to pay for health services that are covered by the health plan (i.e., a copay, coinsurance or deductible), also called a financial requirement.

Deductible – A financial (cost-sharing) requirement imposed by a health plan whereby a patient must pay a specified amount out-of-pocket before the health plan will pay any money for health services. For example, a patient who has a $500 deductible must pay for all health services up to $500 before the health plan begins to pay for claims.

Detoxification or Detox – The process of removing a toxic substance from the body. Medically assisted detoxification may be needed to help manage withdrawal symptoms associated with dependence. Symptom severity depends on the type of drug, the dosage, and how long and how frequently it has been taken. Detoxification is often the first step in a drug treatment program, particularly with addiction to opioids, tranquilizers or alcohol.

Essential Health Benefits – The 10 categories of benefits (e.g., mental health and substance use disorder services including behavioral treatment, preventive services, prescription drugs) that Affordable Care Act (ACA) Plans must cover.

Exchange – An exchange, as created under the Affordable Care Act (ACA), is a place where consumers can compare and purchase subsidized health insurance coverage. Each state has an exchange, operated by either the federal government or by the state.  In Ohio, there is a federally facilitated exchange. 2018 plans and prices are available to view at www.healthcare.gov or 1-800-318-2596.
Please Note that Seniors should direct all Medicare questions to the Ohio Senior Health Insurance Information Program. OSHIIP: 1-800-686-1578

In-network – This is a Treatment Provider who has a contract to participate in a plan’s network. Your plan might specify that you are only permitted to see an in-network provider. You may also pay less in cost-sharing for services from in-network providers.

Individual plans – Health insurance plans not sponsored by an employer or the government. These plans are purchased directly by individuals (typically on the Marketplaces or Exchanges) and must comply with the ACA (including the EHB requirement).

Inpatient – This is a rehabilitation process where a person resides at a facility during treatment. Inpatient treatment is typically reserved for those with more severe substance use disorder problems, particularly where detox may be needed to manage withdrawal.

Inpatient Hospitalization – A patient who is admitted to a hospital or clinic for treatment for more than one night. This intensive level of treatment requires 24-hour care in a safe and secure unit of the hospital. Inpatient treatment is necessary for those who need constant nursing care, those who are severely depressed or suicidal, and those who are unable to break the cycle of their illness in a less restrictive treatment setting. A major focus is to stabilize symptoms and develop a plan for continued treatment of the illness outside the inpatient program.

Intensive Outpatient Program (IOP) – An intensive outpatient program which consists of regularly scheduled sessions of structured addiction treatment and mental health counseling. This option may be suitable for someone who is unable to attend an inpatient treatment program or residential facility and can serve as a middle ground between residential treatment and aftercare. Providers may offer treatment services during the day, before or after work or school, in the evening, and/or on weekends.

Levels of Clinical Care – The levels of clinical care represent a continuum of clinical addiction treatment services, increasing in intensity from level 1 to level 4. Each level of care refers to a broad category of services and treatment formats offered to patients. Developed by the American Society of Addiction Medicine, these levels of care create a universal standard that is used by insurance companies to categorize care types and determine coverage.
Level 1 – Outpatient Services
Level 2 – Intensive Outpatient and Partial Hospitalization
Level 3 – Clinically Managed Low to High Intensity Residential Services
Level 4 – Medically Managed Intensive Inpatient Services

Medicaid – Medicaid is a government funded health care coverage. Medicaid provides assistance to low income and medically vulnerable people. Residents who are eligible for Medicaid are entitled to medical services at no or low cost. For more information about applying for Medicaid in Ohio visit: benefits.ohio.gov.

Medication-Assisted Treatment – The use of FDA-approved medications in combination with psychosocial therapies. MAT Is the most effective treatment for opioid use disorder.

Ohio Department of Insurance (ODI) – The Ohio Department of Insurance (ODI) regulates the business of insurance in Ohio. Its mission is to serve and protect Ohio consumers through fair and efficient regulations, provide assistance and education to consumers, and promote a competitive marketplace for insurers. If you have questions about claim delays, denials and policy recessions or need to file a complaint you may contact the Consumer Services division.

Open Enrollment Period – A specified period during which individuals may enroll in a health insurance plan each year and usually the only time an individual can make changes or enroll except for certain situations, such as a birth, death or divorce in the family.

Out-of-network – This is a Treatment Provider who does not have a contract to participate in a plan’s network. Before receiving services from an out-of-network provider check with your plan to see if you have out-of-network coverage and if your plan has any requirements to receive services from an out-of-network provider (e.g., prior authorization). You may have higher out-of-pocket costs for services from out-of-network providers.

Out-of-pocket – The amount you pay for health care services. This includes services not covered by your plan or services from providers not covered by your plan; amounts that apply toward your deductible; copayments; and coinsurance.

Outpatient – Outpatient treatment programs do not require people to live at the treatment center and are typically reserved for those with less severe needs. This type of treatment can act as a bridge after inpatient care. It can also serve the needs of those who cannot utilize inpatient treatment due to costs or an inability to commit the time away from personal or professional obligations.

Parity Act – Under the 2008 Mental Health Parity and Addiction Equity Act (Parity Act), private and public insurers are obligated to provide comprehensive and equitable coverage for substance use disorder and mental health benefits. The Parity Act requires a health plan’s standards for substance use and mental health benefits to be comparable to – and no more restrictive than – the standards for other medical benefits. Generally, this means that a plan cannot put more restrictive visit limits, impose higher cost sharing or apply more onerous prior authorization or concurrent review requirements on MH/SUD benefits as compared to similar medical benefits or surgical benefits.

Partial Hospitalization – Partial hospitalization programs involve regular onsite treatment, but do not require you to live at the facility. They usually provide 20 or more hours of service per week. They offer ongoing medical monitoring and treatment for those living in a stable environment.

Prior Authorization – A process used by some health insurance companies to determine if they will cover a prescribed procedure, service, or medication.

Qualified Health Plan – A health insurance policy that is sold through an exchange. ACA requires exchanges to certify that qualified health plans meet minimum standards contained in the law.

Residential – Treatment in a residential setting can last from one month to a year. Typically, residents go through different phases as they progress through the program. Sometimes called inpatient, or rehab, these 24-hour supervised Residential Treatment Programs are designed to provide a full array of treatment services.

Small Group Plans – Health insurance plans offered to employees of companies with less than 100 employees. These plans are subject to the ACA (including the EHB requirement).

Substance Use Disorder – Long-term, pathological use of alcohol or drugs, characterized by daily intoxication, inability to reduce consumption, and impairment in social or occupational functioning; broadly, alcohol or drug addiction.

NOTES WITH LINKS

Parity Act: CMS.gov (Centers for Medicare & Medicaid Services)
https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html

Affordable Care Act: U.S. Department of Health & Human Services
https://aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorder-benefits-and-federal-parity-protections-62-million-americans

HealthCare.gov
https://www.healthcare.gov

Ohio Senior Health Insurance Information Program (OSHIP)
http://www.insurance.ohio.gov/Consumer/OSHIIP/Documents/whatisoshiip.pdf

Partnership for Drug-Free Kids – Demand Insurance Coverage of Addiction Treatment
https://drugfree.org/article/demand-insurance-coverage-addiction-treatment/

Ohio Department of Insurance
www.insurance.ohio.gov

Ohio Department of Insurance, Consumer Complaint Form
http://www.insurance.ohio.gov/Consumer/OCS/Pages/ConsCompl.aspx