What Should I Ask My Insurer about My Plan’s Substance Use Coverage?

When you are seeking treatment for your loved one’s substance use disorder (SUD) or mental health (MH) issue, it can seem impossible to navigate how to use your insurance coverage to obtain care. Many of the families who have been through it have likened it to a nightmare.

What many parents don’t know is that, in many cases, your insurance provider is actually obligated to cover your loved one’s care. It’s the law, plain and simple.

(We understand that the language of the insurance landscape is complex. Be sure to visit this glossary of insurance terms if you need help with some of the terminology below.)

To help you navigate this complicated system, here are some important questions to ask your insurance provider when seeking coverage for addiction treatment, to ensure that you are able to use insurance benefits to obtain affordable care for your loved one:

QUESTION: Does my plan cover mental health and/or SUD benefits? And how do I find out for my specific plan?

Many plans do cover MH/SUD and some are required to. If your plan offers these benefits, the Parity Act applies (in most cases).

Remember: Under the 2008 Mental Health Parity and Addiction Equity Act (Parity Act), most private and public insurers are obligated to provide comprehensive and equitable coverage for substance use disorder and mental health benefits if they cover those benefits. The Parity Act requires a health plan’s standards for substance use and mental health benefits to be comparable to – and no more restrictive than – the standards for other medical benefits. Generally, this means that a plan cannot put more restrictive visit limits, impose higher cost sharing or apply more rigorous prior authorization or concurrent review requirements on MH/SUD benefits as compared to similar medical benefits or surgical benefits. For example, if your plan allows for 20 visits for outpatient physical therapy, then it must allow at least the same number of visits for mental health counseling.

The Affordable Care Act (ACA) requires plans sold on the marketplaces (individual and small group plans), as well the Medicaid expansion plans, to cover substance use disorder and mental health benefits as “essential health benefits,” meaning plans must cover those benefits and in compliance with the Parity Act. The ACA does not define the specific benefits that must be covered and allows each state to select a benchmark plan to define the minimum level of benefits in that state.

If you are unsure of your specific benefits, look at your insurance plan’s summary plan description or evidence/certificate of coverage to determine your coverage. This generally can be found on your insurance carrier’s website and if you are still unsure, call your insurance carrier to clarify. You can use the phone number on the back of your insurance card.

QUESTION: What benefits do you cover (including treatment settings and medications)?

Effective care for SUD is provided in different treatment settings or levels of care. The appropriate level of care should be determined by a medical professional, based on a comprehensive assessment. This assessment creates a foundation for an effective treatment plan that is individualized and tailored to meet the patient’s needs. The assessment will determine the level of care that is most appropriate.

The plan may say that it offers both inpatient and outpatient treatment. Inpatient treatment may include treatment in a hospital or a residential treatment facility. Outpatient treatment may be provided in a doctor’s office or clinic. There are also “intermediate” services, which include intensive outpatient and partial hospitalization. The plan may classify these as inpatient or outpatient services.

Ideally, the plan should cover all of these levels of care, and some may require prior authorization. It is important to talk to your provider about the level of care that is covered by your plan that is most appropriate for your loved one. If a patient is placed in a lower level of care than what is needed, his or her needs may not be addressed adequately, but placing a patient in a higher level of care than is needed means the patient may receive unnecessary care at a higher cost.

Depending on the type and severity of your loved one’s addiction and general health status, the use of medications, psychosocial therapies, or both in combination may be necessary. Medications are an effective and, for some conditions, including opioid use disorder, a critical component of addiction treatment.

Ask your insurer what medications are covered and for how long. There are currently three FDA-approved medications to treat opioid addiction: methadone, buprenorphine and naltrexone. Each medication works differently and may be available in different treatment settings. Just like with any other disease, you, your child and your child’s provider should decide which medication works best for your child in their treatment.

QUESTION: What documentation and information should I keep and ask for from the plan?

Keep track of any notices you receive from your plan, including letters authorizing care, denial letters, Explanations of Benefits, emails, as well as any bills that you receive from your provider. Take notes from any phone calls, including the date of the communication, the name of the person you spoke to and a summary of what was discussed.

Ask if any of the services will require prior authorization. Prior authorization is a requirement that your health care provider obtains approval from your health insurance plan to prescribe a specific medication or access a specific level of care prior to providing the service. Failure to obtain prior authorization if required can result in the plan denying coverage for the service, and the patient may be required to pay for the cost of care. Plans may also impose requirements to review a service for medical necessity during a course of treatment. This process is known as “concurrent review.” Ask if the plan requires concurrent review for a service and how often it is required (e.g., every three days). The Parity Act prohibits the use of more onerous prior authorization or concurrent review requirements for mental health and SUD benefit as compared to similar medical/surgical benefits.

Also, ask about your cost-sharing obligations. This is the amount you will be responsible to pay for services covered by the plan (e.g., deductible, copay or coinsurance). It is also important to know whether the provider is in-network or out-of-network. Some plans will not pay for services from an out-of-network provider, or you may have higher out-of-pocket costs for receiving care from an out-of-network provider. Make sure to check with both the health plan and provider about whether the provider currently participates with the plan, and do not rely on plan directories, which are often inaccurate and out-of-date.

QUESTION: What is my deductible and how do any payments I make for addiction treatment apply toward that deductible?

Many plans have a deductible. This is a specified amount that you must pay before the health plan will pay any money for health services. For example, a patient who has a $500 deductible must pay for all health services up to $500 before the health plan begins to pay for claims. The Parity Law prohibits the use of separate deductibles for medical benefits and MH/SUD benefits. You may have separate deductibles for in-network and out-of-network benefits but payments for MH/SUD must count towards the deductible the same way payments for medical benefits are applied.

QUESTION: What if my insurance company says that my loved one’s addiction treatment is “not medically necessary”?

Ask your insurance company to provide the standards that were used to make that determination. They are required to provide you with this information. Additionally, be sure to appeal the decision. When filing a complaint or appeal related to a denial for MH/SUD benefits, make sure to specifically state that you believe the plan is violating federal parity law. Your plan should offer both an internal and external appeal process and you are often required to go through the internal appeal before the external appeal. You have to file appeals within certain timeframes, so make sure you know how much time you have to file an appeal and file it on time. Sometimes the request may be denied because they require specific information from your doctor. Make sure your doctor provides additional information to demonstrate that the service is medically necessary. Bottom line, never accept “no” from your insurance company without appealing.