Health care insurance isn’t always easy to figure out. The language may not be clear, and you may feel a bit lost in conversations regarding your coverage. Despite these challenges, it’s important to thoroughly understand whether the cost of treatment will be covered by your insurance to avoid financial hardship and misunderstandings regarding your care.
The following information is meant to help you navigate insurance issues. If you have questions or need help, talk to a social worker from your medical facility or with a community advocacy group.
Insurance Glossary
Here are some of the insurance terms you may encounter.
copay. A copay is the fixed amount you pay for a covered health care service after you pay your deductible. Some- times, copays are a percentage, such as 20%, and sometimes, they’re a flat fee, such as $20.
deductible. A deductible is the amount you pay for covered health care services before your insurance plan starts to pay anything. For example, if you have a $2,000 deductible, you have to pay the first $2,000 before your insurance starts to pay for submitted expenses.
explanation of benefits (EOB). An EOB is a document sent to you from your insurance company that explains how a service was covered. It includes information about the charges for a service or medication, what the insurance company paid and what you owe.
formulary. A formulary is a list of prescription drugs covered by a prescription drug plan. Also known as a drug list, it’s usually broken down into tiers. Tier 1 drugs are likely to be covered more comprehensively than those in tiers 2 and 3.
in-network. In-network providers have a contract with the health insurance company in which they’ve agreed to certain terms, including specific costs. Your expenses will usually be less with in-network providers and the process may be simpler.
out-of-network. Out-of-network providers don’t have a contract with the health insurance company related to how care is covered or specific costs of care. Seeing out-of-network providers may mean paying higher out-of-pocket expenses or having no coverage at all.
out-of-pocket expenses. Out-of-pocket expenses are the expenses you pay after your insurance company has covered all it’s going to pay. Most policies have an annual out-of-pocket maximum. This means there’s a limit to the amount you have to pay out of your own pocket in a year.
outsourcing. This is the practice in which a treatment facility refers you to a health care provider who’s not part of their program. This can affect your costs since the outsourced providers may not be in-network.
General Information
The federal Mental Health Parity and Addiction Equity Act (MHPAEA) of 2009 requires insurance companies to treat and cover mental health disorders in the same manner as any other health-related problem. The act states that health insurance plans cannot have higher copays and other out-of-pocket expenses for behavioral health claims than for other medical claims. How this act is applied varies by state.
Many treatment programs accept insurance or government payment in the form of:
- State-financed health insurance.
- Medicaid.
- Medicare.
- Private insurance.
- Company-covered services.
Be aware that health insurance providers are not required to cover costs of treat- ment related to relapses. If you relapse, you may need to pay for the treatment yourself.
Most health insurance companies have websites that include information for policyholders, including lists of in-network and out-of-network providers, coverage information and steps in the process. This website is listed on your insurance card.
If you don’t find the website helpful or if you prefer to talk to someone in person, call the customer service number on the back of your insurance card. Allow a significant amount of time to make these calls and be prepared to be placed on hold for quite a while.
Where to start
If you feel that all of this is more than you can handle, consider asking someone to help you make phone calls and gather information.
Make sure to record the names of all people you speak to, contact numbers, and dates and times you talked. You may need to make several calls and it can be hard to remember all the details, so keep notes.
It’s generally best to call the treatment program first so you know what questions you need to ask your insurance company. The program you’re considering may have a website that includes information regarding questions you have.
After you have spoken with the treatment program and have the information you need, then call the insurance company.
Questions for the treatment program you are considering
Key questions include:
- Will staff members arrange insurance preauthorization for you? If yes, is it for all services or only some?
- Are any of the treatment services outsourced? If yes, which ones?
Questions for the insurance company
When talking with your insurance company, these are some of the terms you may need to reference to determine your coverage:
- Addiction treatment services.
- Mental health services.
- Substance abuse disorder services.
- Drug and alcohol rehabilitation programs.
Questions about general coverage
- What services are covered under my plan?
- What services require preauthorization?
- Do I need a physician’s referral for treatment to receive coverage?
- Is the program or provider I am considering in-network?
- If the program outsources some of my treatment to out-of-network providers, how are those costs covered?
- Does coverage vary depending on whether the treatment is inpatient or outpatient?
- How many days of treatment are covered? How many treatments are covered?
- Does my policy cover costs related to relapse?
- Is there any other information I should know?
Questions about copays, deductibles and out-of-pocket expenses
- Do I have a deductible? If yes, how much is it and have I met it yet?
- What is my copay?
- Do my copays vary depending on the service?
- What is my annual out-of-pocket maximum?
Questions about medications
- How are medications for opioid use disorder (MOUD) covered?
- How can I access your list of approved medications (formulary)?
- How can I determine the cost of medications?
If you don’t have insurance
Unfortunately, not everyone has health insurance. Even those who do have insurance may not have enough coverage to afford care. In addition, if an insurance company decides that a certain service isn’t medically necessary, that service may not be covered. This is true even if the service is important to your recovery process.
If you don’t have insurance or if you need help with expenses, contact a social services agency in your community or a community-based health care center that’s government funded. State-sponsored health care coverage typically covers addiction treatment services.
This article is an excerpt from Ending The Crisis Mayo Clinic’s Guide to Opioid Addiction and Safe Opioid Use
Relevant reading
Ending the Crisis
An authoritative guide to understanding the current opioid crisis in America and how it can be solved.
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