What If Insurance Doesn’t Cover All the Treatment I Need?

What If Insurance Doesn’t Cover All the Treatment I Need?

There are insurance policy provisions that affect the amount of addiction coverage for drugs like Xanax

Addiction treatment for drugs like Xanax is often covered by health insurance. There may be limitations to coverage, however, that affect the out-of-pocket costs incurred by patients. Understanding differences in coverage and options for payment can help patients plan a course of treatment that fits their budget.

Insurance Policy Provisions Affecting Coverage

Understanding the coverage provisions of an insurance policy begins with reading it. Most pertinent information can be found in the Summary Plan Description and Evidence of Coverage sections. People who purchase insurance on the individual market generally have a copy of this information. Those who receive insurance coverage through an employer may not and may need to ask for a copy or find the information online.Policy provisions that may affect coverage include the following:

  • Network limitations – The most common types of insurance plans are Preferred Provider Organizations (PPOs) or Health Maintenance Organizations (HMOs). In a PPO, a network of physicians and facilities is contracted to provide care at a lower cost to policyholders. If patients use medical professionals within this network, their costs are covered at a higher rate than if they use out-of-network providers. An HMO plan also uses a network of participating health care providers. In an HMO, however, patients generally pay a flat fee and receive access to physicians within the network. Out-of-network care is often not covered at all. Before planning treatment, it is wise for patients to understand the network provisions of their policies and to determine the rate at which treatment from given providers will be covered.
  • Inpatient versus outpatient provisions – An insurance policy may cover outpatient treatment but not residential care for addiction treatment for drugs like Xanax. There are advantages and disadvantages to each type of treatment, and it is best to make the decision for medical, rather than financial reasons. Generally, residential care is the best choice for people with significant or long-standing addiction issues, but when insurance coverage is limited, it is possible to have a similar experience by combining intensive outpatient treatment with strong social support.
  • Days of coverage – Sometimes a policy will limit the number of treatment days covered. These limitations may be for any type of service, or for particular types, such as for residential treatment. When this is the case, patients may choose to follow residential treatment with outpatient services.
  • Detoxification – Detoxification, often known as detox, is the first stage of treatment. Patients may detox in a hospital or freestanding clinic or may receive detox services in a rehab facility as part of comprehensive care. In some cases, it is possible to detox on an outpatient basis under a doctor’s supervision. Policies may dictate the type of detox they will cover. This may differ depending on the substance of abuse and the likely risks associated with detox.
  • Pre-authorization clauses – Plans may require patients to seek authorization for coverage before accessing medical treatment in non-emergency situations.
  • Referrals needed – HMO plans, in particular, often require patients to get referrals from their primary care practitioners first before receiving care from specialists.
  • Medical necessity – Insurers often base their decisions about coverage on their determination of the medical necessity of a given treatment. This is generally a subjective decision. If coverage is denied because it is not deemed medically necessary, patients have options for appealing the decision. The legal website NOLO gives suggestions for dealing with health plan disputes. These include calling customer service, asking for a notice of denial, asking for an internal review and having an outside organization review the case. In some instances, a case may be taken to court or a complaint may be filed with the state insurance department. For HMO plans, an HMO accrediting organization may be of help.

Sometimes, out-of-pocket expenses are due to the inherent nature of a policy. A high-deductible policy, for example, will not cover anything until the deductible has been met. A policy may also place annual or lifetime financial limits on coverage, and when these have been reached, no more coverage will be offered. If out-of-pocket expenses are beyond a patient’s budget, the options are to supplement finances, cut treatment expenses, or do both.

Payment Options

Although many people rely on insurance help to pay for addiction treatment for drugs like Xanax, a 2010 National Survey of Substance Abuse Treatment Services (N-SSATS) report notes that in 2007, nearly 60 percent of all patients admitted to substance abuse treatment had no health insurance at all. Even for patients with insurance coverage, paying for treatment with more than one funding source is very common. The 2006 National Survey on Drug Use and Health notes that more than half of people who received addiction treatment the previous year used two or more sources of payment. Funding sources included private or public insurance, personal savings, public assistance, loans or gifts from family members and payment through courts, employers or military health care.

Addiction treatment providers understand financial limitations. Some will use a sliding fee scale to charge for treatment based on a patient’s income. It is also common for providers to provide financing and allow patients to make monthly payments they can afford.

Sometimes treatment doesn’t cost qualifying patients anything. The 2006 survey previously referenced found that approximately seven percent of patients received free treatment. The N-SSATS report notes that private non-profit organizations operate the majority of these programs. There are also a limited number of free options through private for-profit and governmental organizations.

We Can Help

If you are ready to pursue addiction treatment, we are ready to help. Consultants who staff our toll-free helpline can answer your questions and help you find a treatment program that fits your personal needs. They can check your insurance coverage for you at no cost or obligation. The helpline is available 24 hours a day, so there is never a wrong time to call. Why not call now?

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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.