4 Things to Know Before Calling Your Insurance Provider About Addiction Treatment

4 Things to Know Before Calling Your Insurance Provider About Addiction Treatment

If seeking to use benefits for addiction treatment to drugs like Xanax, certain information can help when speaking with the insurance provider

The Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) are two critical pieces of legislation that significantly expanded insurance benefits for addiction treatment. Among the many improvements the ACA made addiction treatment a mandatory benefit for marketplace policies, and the MHPAEA said policies covering addiction treatment must provide the same level of benefits as offered for physical health issues. While insurance benefits for addiction treatment are at an all-time high, not all coverage is equal, and insurance companies do not automatically approve benefits. If an addiction develops, individuals should make sure they are properly prepared before calling the insurance provider.

1. Key Words in Insurance Policies

When speaking with customer service about treatment benefits, the representative use a lot of insurance vernacular, and it helps tremendously to know what these words mean. Several insurance terms are common including the following:

  • Co-Pay – Share of the cost for which the patient is responsible
  • Deductibles – Cost amount the patient must first pay before receiving benefits
  • Limits – Maximum cost and days allowed by the policy per year or lifetime
  • Out-of-Pocket Maximum – Point at which the policy covers 100% of additional cost
  • Inpatient – Full-time treatment in a residential care center or facility
  • Outpatient – Part-time treatment with a set number of sessions per week or month
  • In-Network – Treatment facilities with negotiated preferential rates
  • Out-of-Network – Facilities with which the insurer does not have reduced rates

The insurance company might say there are no benefits for out-of-network treatment or reduced benefits for inpatient care. Without knowing the terms a person can easily get lost in the insurance vernacular. Learning the basics can help reduce misunderstandings and confusion.

2. What Questions You Should Ask

When speaking with an insurance provider about addiction treatment, it is important to know what questions to ask. A policy may say it covers addiction treatment, but there are often limits to what services it will cover. Several potential questions can be asked including the following:

  • How the company defines “medical necessity” regarding addiction treatment
  • The difference in criteria and benefits between inpatient and outpatient care
  • The typical number of approved treatment days and the process for adding more
  • Whether or not the policy provides benefits for out-of-network providers
  • What treatment services do and do not require prior insurance approval
  • Which types of detox are covered for the particular addiction

In regards to the latter point, rehab centers commonly offer medically supervised detox that gradually weans the drug from the system. A tapered withdrawal is more comfortable, but if it is a matter of comfort and not medical need, many policies will not cover it. However, a tapered detox is a medical necessity for addictions to benzodiazepine-class sedatives like Xanax since an overly rapid withdrawal can potentially produce fatal seizures. Find out which types of detox the policy covers per the specific addiction.

3. Diagnosis of Co-Occurring Disorders

The HBO: Addiction website says people should insist that their insurance companies cover a complete clinical assessment of their physical and psychological needs. This can help for several reasons including the following:

  • The assessment establishes medical necessity for addiction treatment and other services.
  • A diagnosis of co-occurring physical or mental health disorders may increase benefits.
  • The assessment results provide the basis for asking what services the insurer will cover and for fighting any denied claims.

This knowledge can be important for a person who definitely needs treatment and wants to make sure the insurance company provides maximum benefits. A diagnosis of other medical issues may help the cause. For example, if the liver suffered damage from alcohol abuse, the insurer certainly wants to address the addiction before the liver fails. Similarly mental health disorders like depression or anxiety can also foster physical health issues and intensify an addiction, and integrated treatments like Cognitive and Dialectical Behavioral Therapies (CBT and DBT, respectively) can often address addiction and mental health issues at the same time. The insurer is less likely to deny benefits if a denial might result in higher costs down the road.

4. Know Your Insurance Rights

The ACA provides extensive rights and protections for consumers, and the New York Times added in 2010 that some states have protections that exceed the federal minimums. When dealing with an insurer, it helps to know these rights. If the company ever denies a claim, patients have several potential options including the following:

  • Call the insurance company to make sure it was not a mistake.
  • Ask for written statement stating why the claim was denied.
  • Send a formal written appeal to the insurance company.
  • Include a doctor’s statement on medical necessity with the appeal.
  • File as many appeals as the insurance company allows.

If the company denies the appeal as well, send all of the information (including the statements on medical need and the reason for the denial) to the state insurance department or agency, and request an independent review. To assist with filing appeals to the insurer or a state agency, the Parity Implementation Coalition created a Parity Toolkit to help.

Addiction Treatment Services

A 2011 National Survey of Substance Abuse Treatment Services (N-SSATS) report found that 65% of treatment centers and 85% of mental health facilities accepted some form of private insurance. If addiction treatment for drugs like Xanax is necessary, insurance policies can often absorb many of the costs, and other financing and support options are also available.

Call our toll-free helpline if you have questions about treatment, need a recommendation or even want to check your policy for specific benefits. Our admissions coordinators are available 24 hours a day, so please call now.

Are you ready to seek treatment?

If you are ready to beat a Xanax addiction and start a new life in recovery then we can help. We have admission counselors standing by 24 hours a day to take your email, live chat request, or phone call to get you in the addiction treatment center that best fits your unique & specific needs.