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Insurance Coverage for Alcohol Rehab

Page Overview

If you are unable to stop your alcohol use and are investigating various alcohol rehabs, you have many decisions to make regarding what rehab facility is the best first step of your treatment and recovery journey. The important decisions are influenced by the treatment you need. But unfortunately, the practical decisions are influenced by not only the cost of treatment but whether or not your insurance company will cover your treatment, or you will have to come up with financing on your own.

Understanding insurance coverage can be difficult and frustrating, and the best way to really know what you are entitled to is to contact your treatment facility directly. Some insurance plans will pay for nearly all of your residential alcohol rehab, while others will only cover a portion. Alcoholism treatment is complex, takes time, and requires multiple services such as medical tests, medication, acute detox, residential and outpatient care. As you plan for each phase of your recovery, you will want to fully understand what you can expect from your insurance company and what you will have to pay yourself.

Using Insurance for Alcohol Rehab

When you hear a month of medical model residential rehab can cost from $9,000 to $40,000 per month, figuring out how to pay for alcohol rehab might seem like a daunting task, but the best place to start is looking at your insurance. If you have either group insurance through work, private insurance, or a state program, it is best to understand your coverage and benefits before you look any further. People often try to sift through all the paperwork, benefits books, and handouts to determine what part of rehab their insurance will cover, but they quickly find themselves overwhelmed by the confusing vocabulary and all the fine print.

To really understand your coverage, you could call your insurance company directly, but be aware that they will want to pay out as little as possible, so their answers will be a bit biased and vague, and will not alert you to all your options. Better yet, call an alcohol rehab and enlist the help of the professionals there. These experts deal with insurance companies every day, and they will help you get the most out of your insurance coverage. The first step is determining your insurance coverage. After you know that, you can begin to build your treatment plan, and find additional methods for payment, if necessary.

It is important to deal with a facility with a good reputation that will stand by the financial information they relay to you. Many rehabs are only primarily interested in the money, will tell you your payment is one amount, but then bill you for a much higher amount when you are discharged.

Private and Group Insurance

The Affordable Care Act (ACA), passed in 2010, requires insurance companies to cover behavioral and mental health services as completely as they cover other medical conditions. This means that if the company covers 90% of medical services after a deductible is met, this should be the coverage for addiction treatment as well. Under the ACA, addiction is no longer considered a pre-existing condition for insurance purposes. The bottom line is insurance holders now can enjoy better coverage for their alcohol rehab. The result is that more Americans can get the treatment they need for things like addiction and mental health services. They just need to know how to navigate through the insurance maze.

Even though this is the law, some insurance companies and smaller employers don’t have to comply, and to keep costs down, won’t offer mental health or addiction coverage. Again, these loopholes make it important for you to have someone who knows the system talk to your insurance company directly and on your behalf to get to the bottom of what coverage you have and what is the best ethical way to access the coverage you have been paying for or promised.

Keep in mind that better or high premium insurance usually provides more options while covering more services at a higher percentage. Insurance companies can still only pay for a portion of a person’s medical services, depending on the amount of coverage the employer purchased. Some high premium and better insurance plans will cover all or nearly all of an individual’s detox, inpatient, and outpatient rehab. An individual with a lower premium pays less monthly for insurance, but can expect to have to pay for more of their rehab out-of-pocket.

Other variables in your treatment costs are the deductible and copay. The deductible, similar to a car insurance deductible, is a dollar amount you have to pay first before the insurance will pay. Usually a cheaper premium has a higher deductible. The copay is an amount you are co-paying with the insurance company. For residential stay, a copay can be several hundred to several thousand dollars. Some residentials are able to waive or lessen this. It is good to have someone who knows the system negotiate on your behalf. Outpatient copays might be $10-75 depending on whether it is an MD or a therapist.

Medicare

Medicare is a federal government-sponsored plan for individuals over the age of 65 or who have a chronic disability. Medicare is for those on social security, either for retirement or disability, and provides medical and mental health insurance. In general, Medicare covers the majority of the cost of addiction treatment. However, since Medicare does not reimburse the facility like other insurances, has many restrictions and requirements, and is difficult for treatment centers to work with, most treatment centers do not accept Medicare payments. Due to restrictions on what type of care and length of treatment Medicare will cover, it is helpful to contact your treatment center or a qualified placement specialist to find out specifics.

Medicaid, also Called Medical Assistance

For low income individuals and families, Medicaid provides much-needed health coverage, including mental health services. Each state is in charge of their own Medicaid and creates their own regulations, so leaving the state for treatment with Medicaid is not allowed. Also, because of the many regulations and the low reimbursement to the treatment providers, very few facilities or agencies accept Medical Assistance. It is important to call the number on your Medicaid card to find out the clinics or rehab facilities in your area that will accept your Medicaid or medical assistance. You can also call your local hospital’s Emergency Department, and ask to speak with the Addiction Crisis worker, and they can tell you the number for the clinic or rehab facility which accepts your Medicaid. Lastly, you can call the facility you are interested in to see if they accept your state’s Medical Assistance.

Because of the ACA, Medicaid coverage for addiction and mental health services has been greatly improved. Today, Americans on Medicaid can expect to receive the same kind of coverage for their alcohol addiction rehab as for any other health condition. Under the ACA, when you receive treatment from a Medicaid provider, covered services generally include screening, family counseling, inpatient detox, residential rehab, intervention services, and even medications and are usually fully covered by Medicaid.

What Private Insurance Covers

The American Medical Association now recognizes addiction as a disease, thus insurance companies are required to cover costs associated with treating this illness. However, no two insurance companies are alike, and coverage can vary drastically, even from one person to the next depending on what your employer chooses and sometimes what you have chosen.

The key phrase you will commonly hear is Medical Necessity. Medical Necessity is the term insurance companies use to distinguish or stamp the services they deem medically necessary for alcoholism treatment from the services that might be nice or beneficial, but they believe aren’t medically necessary. Insurance will only pay for the medically necessary services. Reviews by the insurance company are done every few days and the insurance evaluates, based on your improvements, what services they feel are truly medically necessary, and thus what they will pay for.

So as we discuss all the following services, keep in mind that your insurance might list them as covered services, but only if they are deemed by your insurance, NOT your treatment provider or facility, as medically necessary at that moment. The following are common services needed for addiction treatment – check with your preferred rehab choice to see if these costs will be covered for you.

Assessment or Screening
The first step to getting treatment is often an initial level of care assessment. This determines how advanced the alcohol addiction is and how what level or intensity of treatment is needed. Physicians and therapists are screening right in their offices for things like alcoholism, drug addiction, and mental health issues. With these services being covered more completely by insurance, this means a greater number of people are being directed to treatment for their addiction earlier, which means less suffering, more hope, and an easier path to a full recovery.
Medical Tests
As part of the initial assessment or ongoing treatment process, treatment providers often conduct a series of medical tests, like blood and urine tests, or brain imaging, like CT or MRI. These are helpful for assessing the patient's alcoholism, diagnosing medical or psychiatric conditions, and determining the type of detox, psychiatric, and medical treatment that is needed. Depending on your benefits, most, if not all of these tests, could be covered.
Detox
Because detox is primarily a medical treatment, some insurance companies will cover detox from the medical benefit, and some from the mental health benefit. So detox can sometimes be sticky if you or your employer has tried to save on the premium by cutting our mental health coverage. Most insurances cover detox, but they might not cover the intensity of medical supervision at higher end facilities or might limit the days they will cover. Usually 4-7 days are needed. Some plans fully cover medical detox, while others only allow for non-medical detox. It is important that you enroll in the type of detox you need for your own safety and wellbeing, so ask what is the highest level of detox your insurance will cover.
Medication
Medication is used during detox and in many instances after detox to curb cravings, treat medical problems from the alcoholism, or psychiatric issues like anxiety or depression that often occur with alcoholism. Medications are almost always covered, but some insurances do not cover the newer, more expensive medications, so it is important to find out if the medication is covered. If not, find out if there is an alternate medication they will cover to treat the same issue.
Inpatient Services
Insurance will usually cover at least part of a person's inpatient rehab. Restrictions as to the length of treatment, facility type, and different services covered will usually vary, so check with the intake professionals at your facility to clarify what is included in the insurances daily inclusive payment and what would be an add on you would have to pay out-of-pocket if you desired that treatment.
Partial Hospital Program (PHP) or Intensive Outpatient (IOP)
A less structured level of care, this is 9-30 hours per week usually while living at home, a recovery house, or supervised apartments. This is mostly often covered by insurance as long as you go to someone in your insurance’s network and only as long as your insurance feels it is medically necessary (usually 3-8 weeks). Often times you will pay a copay or be responsible for some portion, as insurance will rarely cover 100% of the outpatient fee.
Individual and group counseling
Like PHP or IOP care, individual and group counseling is usually covered by insurance, although some companies put tight restrictions on session format, kind of therapy, length of time, and frequency of sessions. Again, insurance only covers as long as you go to someone in your insurance’s network and only as long as your insurance feels it is medically necessary. Often times you will pay some copay or be responsible for some portion, as insurance will rarely cover 100% of the outpatient fee.
Christian or faith based treatment
Bringing in a divine component and the healing principles and teachings of Jesus and the Bible are the most powerful and quickest way to recovery and transformation. Insurance will pay for these if they are part of a good therapy process by licensed clinicians trained to integrate Christian principles into sound cognitive behavioral and psychodynamic therapies. Insurance won’t pay for Bible studies, prayer groups, or church services. Many medical programs providing insurance covered therapies soundly integrate Biblical healing for great results.

How to Best Utilize Your Coverage

Most people with insurance will find that regular doctor visits are covered, and this is a great place to start. Visit your doctor for an assessment to help determine your needs. Be very honest with how much you use, the consequences and struggles in your life, and your desire to stop drinking but having trouble stopping without intensive help. Your doctor can point you in the right direction as far as the level or intensity of care you should need, and your visit will also be documented in your medical records, showing your need for rehab. Find out how to select the right rehab for your needs here.

As much as cost is going to be a concern, your recovery is determined by finding the right rehab for your needs. You should contact various rehab centers or a referral organization to find what each facility offers and how the program will work for you. The most unbiased help you will get will be from a case management or referral agency that doesn’t own a facility. Once they help you find the best option for your addiction, find out if they accept your insurance. If they don’t, you can look for other rehabs that are similar to the one you want that do accept your insurance.

Finally, be assertive and don’t be afraid, embarrassed, or shy to ask questions to find out what will and will not be covered at your rehab of choice. If you find there are too many extras that you want but your insurance won’t cover, you might need to limit your choices or be prepared to pay for some of these services out-of-pocket.