According to the Addiction journal in 2006, professional rehabilitation essentially doubles the likelihood of a positive recovery outcome. Still addiction relapse rates provided by the National Institute on Drug Abuse (NIDA) in 2010 range from 40% to 60% and are influenced by factors like the substance abused, the severity of the addiction, co-occurring disorders, unemployment and treatment duration. The Journal of the American Medical Association described the rates as comparable to relapse rates for type two diabetes, hypertension, asthma and other medical conditions, and professional treatment remains the most effective way to overcome addiction. Nevertheless some recovering addicts have setbacks and require remittance into rehab, and insurance may cover the additional visit depending on the company, policy and the past use of benefits.
Health Insurance Rehab Coverage
A 2002 policy paper by the Centers for Disease Control and Prevention (CDC) stated that every dollar spent on addiction treatment reduces drug-related health, theft and criminal justice costs by up to $12. For this reason many insurance companies see treatment as a cost-effective preventive measure, and policies with treatment benefits generally include basic detox and rehab. Still several factors must be considered when seeking rehab benefits including the following:
- Insurance companies do not automatically approve benefits in the policy.
- Companies may deny claims that they deem are not a medical necessity.
- Special medical detox may be restricted to certain substances like benzodiazepines.
- Insurers may approve outpatient treatment but not inpatient care.
- Co-occurring mental health disorders often allow for additional days.
- In-network treatment typically has better coverage than out-of-network.
- The number of rehab days allowed may be subject to regular reassessment.
As far as multiple rehab visits, insurance companies typically look at the total number of days in treatment rather than the number of times an addict enrolls. Likewise after a certain number of treatment days, the co-pays (i.e., the patient’s share of the cost) are likely to go up, and policies often have annual and lifetime limits on treatment days and costs.
Recent Changes to Rehab Benefits
Individuals who had addiction treatment in the past may find they now have more insurance benefits. Recent legislation has produced several positive changes including the following:
- Mental Health Parity and Addiction Equity Act increased benefits by prohibiting coverage discrimination against behavioral health treatments.
- Affordable Care Act (ACA) made addiction treatment one of its ten essential health benefits required of insurance exchange companies.
- The ACA also prohibits insurance companies from denying coverage to people with preexisting conditions such as addiction and mental illness.
The New York Times also points out that states often have their own required level of insurance benefits that may differ from federal minimums. Pennsylvania, for example, requires a minimum of seven detox days, 30 non-hospital rehabilitation days and 30 outpatient sessions per year. The higher minimum either set by the state or federal government is the one that applies.
Insurance Claim Tips
In utilizing health insurance to cover rehab, there are several important tips to remember including the following:
- Note what the policy does and does not cover and what benefits require prior approval.
- Make sure the doctor also knows what is covered and what requires prior approval.
- Be clear on which treatment providers are in-network and out-of-network.
- Call the customer service line if the insurance company mistakenly denies a claim.
If the company says the claim denial was not a mistake, patients have several potential options including the following:
- Submit a formal written appeal with a physician’s statement regarding the medical necessity of the treatment.
- Some plans allow for multiple appeals if the first one was also met with a denial.
- Certain states allow for an independent review by its insurance department or agency.
- Potential third-party reviews and arbitration.
The key is to be informed, organized and persistent.
Addiction Treatment Services
Many recovering addicts return to rehab after a relapse or setback, but a person who is struggling to prevent a relapse can also benefit from additional treatment. In either case treatment centers provide a variety of effective services including the following:
- Supervised detox with medical options as needed by the patient
- Evaluation of which recovery therapies and strategies were and were not helpful
- Analysis of internal and external factors that contributed to the recovery setback
- Determination of which substance abuse triggers continue to cause problems
- Further use of behavioral therapies to reshape negative thought patterns and beliefs
- Counseling for unconscious conflicts, unresolved trauma and unhealthy motivations
- New screenings and integrated therapies for mental health and personality disorders
- Optional holistic therapies like acupuncture, massage, hypnosis and yoga
Relapsed addicts without insurance or who have exhausted their treatment benefits still have options. Government and non-profit assistance programs are available, and many treatment centers have payment plans. Fortunately help is available to sort through the options.
Free Addiction Helpline
If you have questions, call our toll-free helpline 24 hours a day. Our admissions coordinators can look up your insurance policy and explain the plan’s rehab benefits. We can also explain the different treatment options, recommend in-network providers and provide information on assistance programs. We are here to help, so please call now.
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