According to a survey by the Substance Abuse and Mental Health Services Administration (SAMHSA), nearly 23 million people need substance abuse treatment every year. Sadly, only about 11% of them will actually receive it.

If you have health insurance, then you should actively pursue getting into a drug rehab. In 2014, the Obama administration passed a law stipulating that insurance companies must cover mental health and substance abuse programs. It also doesn’t allow the insurance companies to deny coverage based on “pre-existing conditions”. So, if you or a loved one are wondering how to get your insurance company to pay for drug rehab, keep reading.

What Are The Different Types of Rehab That Are Covered?

Many people don’t realize that there are multiple types of treatment facilities. In fact, the National Institute on Drug Abuse (NIDA) estimates that there are over 14,000 treatment facilities in the US.

These different facilities include:

  1. Inpatient detox is necessary for a severe physical addiction to drugs with serious withdrawals.
  2. Outpatient detox is used for a mild to moderate physical addiction to drugs with withdrawals.
  3. Partial hospitalization is necessary if the patient is experiencing life-threatening withdrawals like seizures or psychosis.
  4. Inpatient rehab is necessary if the patient has a serious or long-running physical and/or psychological addiction. This is usually 30, 60, or 90 days, or 6 to 12 months.
  5. Outpatient rehab is used if the patient has a mild to moderate physical or psychological addiction. This is usually 30, 60, or 90 days.

When trying to decide what kind of rehab to attend, it’s absolutely essential that you be honest with your physicians and the insurance company. That way, the best choice for your particular situation can be made.

For example, it’s fairly common for insurance companies to incrementally increase the coverage they grant for treatment. In other words, the first time they may approve a 90-day outpatient treatment. If the treatment doesn’t take, then they may next approve a 60-day inpatient stay. If that doesn’t take as well, then they may approve a 90-day treatment stay. It all depends on the type of insurance.

Does Health Insurance Pay for Rehab?

Yes, absolutely. But there are certain conditions. These include:

  1. The use of “in-network” facilities or doctors to get full coverage.
  2. Only allowing detox in a hospital as part of the full coverage plan.
  3. There are variations in coverage depending on the type of treatment (inpatient, outpatient, or detox).
  4. Switching the coverage based on the length of treatment (30 days, 60 days, 90 days, or 6 months).
  5. Denying the coverage if you’ve had drug treatment in the past.
  6. Switching the coverage based on the type of addiction.

As you can see, there’s a lot to navigate when trying to get your health insurance to pay. In other words, you’ll have to look into the details of your plan. This is best done by contacting your insurance company directly and speaking to one of the representatives. They can then go over these conditions and advise on how best to proceed.

As a policy holder, you have a fundamental right to ask your insurance plenty of questions. So make sure you ask about the nature of the coverage and how they’ll cover any sort of drug rehab.

The Differences Between HMO and PPO for Drug Rehab

The two most common health insurance plans are HMO and PPO. So what are the differences between the two?

  1. HMO (Health Maintenance Organization) plans give patients the choice in their primary care physician (PCP). As a result, they can form a strong relationship with a physician who knows their entire health history. If a patient is suffering from substance abuse or addiction, this may be especially helpful. However, with HMOs, you need a referral from your PCP to seek out a specialist outside of the network. This can include seeking out an addiction specialist. Additionally, HMOs have lower or no deductibles and overall coverage is usually cheaper. As a result, HMOs are best if you are not planning on seeing anyone out of network.
  2. PPO (Preferred Provider Organization) plans give patients the choice to see healthcare providers in and out of the network without any referrals. That means you can see an addiction specialist without having to get a referral from your PCP. This is the main benefit of a PPO over an HMO plan. However, PPOs usually have higher deductibles than HMOs.

To boil it down in simpler terms: HMO is more affordable and PPO is more flexible. Generally, with an HMO, you’ll have to go through a few more hoops to get coverage for rehab. Your PCP may have to refer you to a specialist or facility. On the other hand, with a PPO, you can usually just contact the rehabs directly to see if they’re covered.

Are Relapses Considered Pre-Existing Condition?

You may have heard the concept of a “pre-existing condition” in regards to insurance coverage. This can be a source of anxiety for a lot of policyholders when trying to get coverage for a health condition, including substance abuse.

So, if you’re reading through your policy and you encounter the phrase “pre-existing condition”, then there’s a few things you should know. First of all, relapses are considered a part of substance abuse recovery. They’re incredibly common and are not frowned upon within the recovery community.

It’s important to understand that if you have relapsed after having gone through rehab, then that may be enough to approve your insurance coverage. Remember, relapses are common. However, there’s a possibility that you’ll have to meet more stringent conditions in order to be approved for rehab again. From the viewpoint of your insurance company, they’ll want to avoid a situation where rehab becomes like a “revolving door” for you. But if you meet these conditions, then it’s highly likely that they’ll cover the treatment.

How Do I Find Covered Treatment Near Me?

There are a few resources available to anyone looking to get coverage. Let’s go over each of them.

  1. First and foremost, contact your insurance company. Remember, as a policyholder you have every right to know the ins and outs of your coverage.
  2. If you have an HMO, then ask your doctor for a referral to an addiction specialist. They’ll know the best next step for treatment under your coverage.
  3. If you’ve found a specific facility (or have been referred there), then they’ll have an “admissions navigator” who can work with your insurance company to get you maximum coverage.
  4. Use our directory as a guide and search through numerous quality treatment centers near you for help with breaking your addiction.

Even if you don’t have insurance, many treatment centers offer payment plans and can help you get treatment regardless of whether or not you have insurance. Don’t let not having insurance deter you from seeking treatment. There is always a way to get help.

You don’t have to face this challenge alone, so be sure you use these various tools and resources. It’s important to remember that addiction is a disease that is best treated by medical professionals. So start your new, sober life today and reach out for help. 

Sources:

  1. National Survey on Drug Use & Health – 2013
  2. Mental health & substance abuse coverage
  3. Principles of Drug Addiction Treatment (3rd Edition)
  4. Treatment Statistics
  5. Addiction Treatment

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