Using private insurance for addiction treatment

An in-network clinic has a contract with your plan and has agreed to set prices. An out-of-network clinic has not.

Go out of network and several things can happen at once. The plan may pay a smaller share or nothing. A separate, higher deductible may apply. The clinic may bill you for the difference between its price and what the plan pays.

This is the most common way people end up with a large bill for rehab. A program saying “we work with your insurance” is not the same as being in network. Ask the insurer, not only the program.

Prior authorization means the plan wants to approve a service before you get it. It is common for residential stays and for some medications. The clinic usually files the request, but you can ask them to confirm it was approved before you start.

The federal parity law limits how far a plan can go. If a plan covers substance use disorder care, its copays, visit limits and approval rules for that care cannot be more restrictive than the ones it uses for medical and surgical care.

The catch: the parity law does not force every plan to cover this care in the first place. It applies to most larger employer plans and to individual plans. Marketplace and small-group plans must cover it under the Affordable Care Act.

If your plan seems to treat addiction care more strictly than other care, you can ask it in writing for the reason it used. For job-based plans, the U.S. Department of Labor handles parity questions. For plans you buy yourself, your state insurance department does.

Call the member services number on the back of your card. Have the clinic’s name and address, and the service it recommends.

1. Is this clinic in network for my plan?
2. Is this service covered: outpatient visits, medication, intensive outpatient, residential?
3. Does it need prior authorization, and who files it?
4. How much of my deductible have I met this year?
5. What will my copay or coinsurance be for each visit and for the medication?
6. Is there a limit on days or visits?

Write down the date, the representative’s name and a reference number for the call. If the answer later changes, that record matters.

If you are on a parent’s or spouse’s plan, the statement of what was paid may go to the policyholder. You can ask the plan to send your mail to a different address. More on this is in your rights and privacy in treatment.

A denial is not the last word. You have two rights under federal law.

• Internal appeal. You ask the insurance company for a full and fair review of its decision. If your case is urgent, the company must speed this up.
• External review. You take the appeal to an independent third party. The insurer no longer gets the final say.

Your denial letter has to tell you why the claim was denied and how to appeal, including the deadline. Read that part first.

Ask your clinic to help. Treatment programs file appeals often, and a letter from your prescriber explaining why the care is needed carries weight.

While an appeal runs, you still need care. Ask your prescriber what care you can start in the meantime, such as outpatient medication treatment. You can compare programs in our treatment directory, or read the wider picture on treatment costs.