Treatment programs and practitioners get paid from three sources:
- private health insurance
- Medicaid and Medicare (public insurances)
- public funds that are a combination of federal and state government dollars (for patients that have neither public nor private insurance)
Five Things To Ask About Insurance When You Get Treatment
1. Am I insured? What are my health insurance benefits? What are the deductibles, co-pays, annual and lifetime limits of my insurance benefits?
Often health insurance has rather severe limits on what type of treatment services it will reimburse; health insurance typically has higher co-pays for treatment of substance use disorders than it does for other types of medical care, and usually there will be a limit on how many days and how many times in the course of a year it will pay for treatment. Typically, insurance pays for a limited number of outpatient sessions (generally 30) and a very limited set of inpatient hospital or residential treatment days per year. Many insurers also impose lifetime limits on the amount of care covered by the policy and caps on the number of times you can be treated for substance use and addiction.
Insurers often use nurse practitioners to make decisions about access to and continuation of treatment. This "management" of continuing care often means that the treatment program must get permission every 10 sessions or, for inpatients, every three days, to continue treatment services. Some treatment organizations find this requirement a nuisance but if they do not comply reimbursement will be stopped and it may be necessary to discharge the patient.
2. What are the criteria the health insurance company will use to decide if it will allow admission to treatment and will pay for the treatment?
Often when you call the insurance company's 800 number to get permission to access services, there will be a nurse practitioner at the other end. The nurse practitioner uses what is called "medical necessity criteria" to decide whether and in what settings (inpatient, residential, outpatient) the insurer will pay for treatment services. Although we know that there are other criteria that should be applied in making decisions about coverage, at present health insurance companies use only medical necessity criteria. If your insurance does not think these criteria are met, you may be denied access to treatment services. Gaining access to hospital inpatient care is generally very difficult.
There are no standards for "medical necessity criteria" and how the decisions are made. There is no specific or consistent criteria for approval and the standards used to determine if an individual is eligible to receive care vary. The medical necessity criteria used to deny access treatment will not be revealed.
It is very important that you insist that insurance pay for a full clinical assessment that identifies all of the physical and psychological problems that need to be addressed by treatment and other services you may need to have access to during treatment, such as child care, educational/vocational services and the like. You need to ask whether these services will be included as part of treatment or whether they have to be paid for separately.
3. If Medicaid is paying for my or my child's treatment services, what do I need to know about the treatment provider I want to use?
If you qualify for Medicaid by reason of income or disability, that does not imply that all treatment settings will be available to you. Treatment providers must be certified as "Medicaid-eligible" to provide treatment services and receive Medicaid reimbursement. Medicaid limits the types of services and settings it will reimburse. Before your child or adolescent enters treatment you must ask what services will be reimbursed. Medicaid is considered a state program which means that what services are paid for and which treatment programs are identified as "Medicaid eligible" differs by state.
4. Will someone coordinate the care that is being reimbursed? Who? Where are they located and how to I reach them?
Often a private health insurer and/or Medicaid will identify someone, often a nurse practitioner, to coordinate or "manage" the care provided. It is very important to know who that person is and to communicate with them directly. Care managers also may be used to track whether a patient is moving through levels of care.
If there is no care manager, demand that the insurance agency provide one. Health insurance companies are contracted to provide and pay for this service. If the care manager is inadequate, go to the supervisor to request better care.
5. If I use my health insurance, who else will know my child's problem? Will the record follow him or her? For how long?
Health insurance privacy protection is provided by the federal privacy laws HIPAA and 42 CFR Part 2 (which is specific to substance use privacy protection). However, under some conditions it may be very important for other professionals to know about a child or adolescent's substance use treatment history and current treatments. Information and guidance are available for every parent about how to handle the issue of privacy. It is also true that there are conditions under which no privacy protections exist. For example, if the police suspect that a crime has been committed involving drugs or alcohol they are permitted to access treatment records of any clinician, including unfortunately, therapy notes.
Home Box Office, Inc.
The Addiction Project
written by: Mady Chalk, Ph.D.