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

Health insurance often covers addiction treatment. Understanding the coverage offered by a policy can help people make informed decisions about possible treatment plans, so many people choose to contact their insurers before deciding on a plan of action. Understanding some basics about insurance coverage for addiction to drugs like clonazepam can help people better understand the issues and know what questions they might want to ask.

Insurance Coverage for Drug or Alcohol Addiction

Important things to understand about insurance coverage for addiction include the following:

  1. Most plans cover substance abuse treatment to some degree, but it is still possible to have a policy without addiction treatment coverage. It is uncommon because most states have regulations requiring some degree of coverage for plans sold in their jurisdiction. The gov website explains that under the Affordable Care Act, all health plans offered in the small group and individual markets must offer a certain number of services, known as essential health benefits. Among the benefits is treatment for substance use disorders including both pharmacological and behavioral therapies.
  1. Plans differ in the type of treatment covered. The first phase of addiction treatment for drugs like clonazepam is detox, in which drug and alcohol withdrawal symptoms are monitored and managed and patients are made as comfortable as possible. In a publication titled “,” the National Institute on Drug Abuse notes that detox is important, but it is rarely enough to put patients on the road to long-term recovery without further post-detox treatment. Although it is increasingly less likely, some insurance plans may cover only detox and no ongoing treatment.

Post-detox treatment can take place on either an inpatient or outpatient basis. When patients attend inpatient or residential treatment, they live on the facility grounds and can devote all their time and energy to the work of recovery from addiction to drugs like clonazepam. For outpatient treatment, on the other hand, patients live in their own homes or elsewhere and attend treatment sessions in a clinic or other setting. It can be a good choice for patients with less serious addictions or for those with employment or family responsibilities they wish to maintain. Because outpatient treatment is less expensive, some insurance policies cover only outpatient treatment and do not offer coverage for residential rehab.

  1. Plans may place limits on coverage. This may include the number of days covered in a residential facility or the number of outpatient visits allowed. Policies may also have an annual or lifetime monetary cap, which limits the insurance company’s total financial liability. Fortunately because of parity laws, including the Mental Health Parity and Addiction Equity Act (MHPAE), passed in 2008, group policies that offer coverage for addiction treatment must offer it on a level equal to that of other medical conditions. Co-pays, deductibles, out-of-network coverage and financial limits must be equivalent.

Coverage may also differ by provider. If an insurance plan is part of a preferred provider organization (PPO), treatment from physicians and medical facilities that are part of the network will be covered at a higher rate. If the policy is part of a health maintenance organization (HMO), treatment from non-network providers may not be covered at all.

  1. Insurers limit coverage to what is considered medically necessary and have a degree of latitude in determining that. A determination of medical necessity may be made when making initial coverage decisions and also for determining continuing treatment. Some insurers, for example, will cover a certain number of days in a rehab facility but require ongoing assessment before authorizing further time there. Insurers may also use medical necessity criteria to determine whether residential treatment will be covered.

One provision of the MHPAE was to require insurers to inform policyholders of the criteria used for determining a treatment’s medical necessity. Some develop their own guidelines for care and others use guidelines developed by another source. Insurers rely on information developed by such groups as the Substance Abuse and Mental Health Services Administration, the American Child Academy of Child and Adolescent Psychiatry and the American Society of Addiction Medicine. A 2013 article in the New Jersey Star-Ledger notes, however, that treatment criteria may be subjective and open to interpretation, leading to variability in coverage.

We Can Check Your Insurance Coverage for You

If you are curious about your health insurance coverage, we can check it for you, at no cost or obligation. Our toll-free helpline is staffed 24 hours a day with helpful and knowledgeable consultants who understand the variations in coverage and know the questions to ask. They can help you understand your treatment options and find a program that meets your needs. Addiction to drugs like clonazepam is a serious but treatable disease. Why not call now?

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