Insurance Benefits for Substance Abuse

Addicts looking for treatment services covered by existing insurance providers are going to run into several trends. One being that residential treatment services are based on the need for treatment at a medical level. If an addict exhibits signs and symptoms of more than one mental health diagnosis, he may be eligible for inpatient treatment, due to the recognition that medical (usually psychiatric) medical intervention is necessary to treat his condition(s) appropriately while they become detoxed from their substance(s) of abuse. The user is likely to be granted inpatient services for ongoing treatment, due to the recognized difficulty of stabilizing his mental health condition without relapse into addictive behaviors and substance abuse once again. This takes time and must be overseen by a physician.

Insurance Coverage of Medical Detox

Those with addictions that require medical detoxification will be authorized that service in a medically-monitored agency, usually a hospital or clinic, sometimes a rehab with medical oversight and supervision. For those who are medically at-risk for additional medical concerns, there are psychiatric hospitals and treatment agencies in hospital settings where referral will be made. Otherwise, it is common for detoxification, even though it is termed “inpatient hospitalization” to be done at an agency that is adjacent to or overseen by a hospital staff. The treatment will be medically appropriate, but not full hospitalization, for the most part. One that fits into this description is Aetna. They now package and provide many types of plans for their members. If criteria is met for admission, they will follow the member from day one and give only what is needed for one week of treatment at a time, beginning with detoxification. Often, the member will be referred to the least amount of treatment deemed appropriate for the amount and time using/abusing substances, age, general health (both physical and mental), and types of substances. Another important factor that will determine coverage is whether you belong to an HMO or PPO insurance plan. If referred to inpatient services, this will (usually) be monitored weekly for progress. As the need for an additional week of services is determined, authorization by their insurance provider will be made. Seldom is more than 7-10 days approved at any given time. There is usually a 21-30 day cap placed on benefits for inpatient treatment. It is recognized that expenses incurred with inpatient treatment are seldom justified for treatment efficacy. Therefore, it is commonly short term. Outpatient treatment allows the member to remain in their home environment, after the detoxification period. Most insurance benefits will generally allocate 30-60 days of service for outpatient treatment. There is an allotment with most policies for intensive and step-down programs, with additional services to extend to up to a year, with aftercare to keep the member engaged in ongoing abstinence for that period. Such a treatment package is usually available for most members.

Long-Term Addiction Treatment and Insurance

Exceptions will be made for chronic, long-term abuse and dependence, as well as for those who are seen as high-risk due to other medical or mental health factors such as co-occurring disorders, where there is an addiction and a mental health diagnosis (such as depression) that is complicating treatment and addiction. These are circumstances where long-term and/or intensive inpatient treatment may be indicated for the member. As for insurance coverage, these will need to be determined on a case by case basis. A good example of this is seen with those who serve in combat and their substance abuse is directly linked to their post-traumatic stress disorder. TRICARE, the insurance benefit package for military personnel and their family, has developed very structured program services for the co-occurring disorders of substance abuse and a mental health diagnosis of PTSD. When a member is looking for treatment services for their substance use/abuse, it is important to understand what is being agreed upon. Too many times, people are told they have access to benefits and travel to a treatment program that is not covered by their provider program or run out of benefits after a few days. When this happens, they face a difficult choice, to stay and incur personal debt for the balance of the services (if the agency is willing to allow that, and many do) or to leave after only a few days and return home to seek other options for treatment. Both are difficult and potentially dangerous options. Better to be sure about the agency and its fees before embarking on that journey. Know all the options and be sure to get more than one opinion.