Will My Insurance Cover Opiate Addiction Treatment?

Will my insurance cover opiate addiction treatment?

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No one wants to battle with an insurance company while struggling with an opiate addiction. In fact, the growing number of people addicted to opiates spurred the federal government to pass new rules to make treatments more available and better.

Beginning in 2014, federal law mandates most insurers cover addiction treatments. Under the Affordable Care Act people who buy coverage on a state health insurance exchange or receive coverage through Medicare or Medicaid have policies that cover substance use disorder along with mental health disorders. Other Americans covered by their employers also have addiction and mental health coverage. The coverage expansion is crucial because more Americans than ever suffer with an opiate addiction.[1]

Opiate addictions rose dramatically in the 1990s and 2000s for several reasons. More people received prescriptions for pain relievers as part of a movement to better treat pain, drug manufacturers released new and stronger pain relievers and more pills were shared between family members and friends.[2] An estimated 1.9 million people age 12 and older had a pain reliever addiction in 2014; 4.3 million people reported nonmedical use of pain relievers. While heroin use is less common, it is growing. An estimated 586,000 had a heroin addiction in 2014.[3]

Addiction Treatment Coverage

In addition to ACA requirements that mandate insurance policies cover addiction and mental health, there are further protections for Americans. Insurers also must cover people with pre-existing conditions, which includes anyone previously treated for addiction or other mental health disorders. This gives people ongoing access to addiction treatment even if they were denied in the past.

Federal laws also require most group health plans charge members the same copays and coinsurance for mental health benefits as they do for other medical/surgical benefits. Still, an insurer’s total package of benefits varies by state, and a person should discuss individual policy requirements with his addiction treatment center.

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Getting Addiction Treatment

Now that more people have access to addiction treatment, it’s good to know the best way to get necessary treatments. Many insurance companies require a medical diagnosis before covering certain treatments, including addiction. When seeking treatment it’s best to consult with a physician, psychologist, psychiatrist or addiction specialist about unique needs and provide honest answers about challenges with behaviors.

Health insurers pay for services based on a patient’s needs. If a patient experiences symptoms, such as feelings of intense sadness, and does not communicate the symptoms, he may not get needed treatment. Getting treatment for all health conditions is important, because of the chronic, recurring nature of addiction and mental health disorders. It is common for people with an addiction to also have a co-occurring disorder, such as a mental health disorder or other chronic disease. The most effective addiction treatments address a person’s mental and health conditions at the same time.[4]

Insurers also may require prior authorization before approving services, so it’s important to call ahead to find out what’s needed before beginning treatment. Insurers make decisions about the services they will cover based on a person’s medical needs. Known as medical necessity guidelines, these requirements cover a person’s immediate symptoms and needs. While a person may want to begin getting sober before entering treatment, it’s important to wait until entering a facility to make sure potentially dangerous withdrawal symptoms are monitored by medical staff.[5]

Need Help Finding Opiate Addiction Treatment?

The easiest way to find opiate addiction treatment is to call our toll-free helpline and speak with an experienced admissions coordinator We offer counseling about a wide variety of treatment services, and our referral service is always free. We work with the best treatment centers in the United States and can verify your benefits for these services.

When you decide on the treatment that fits you best, we will work with your insurance company on your behalf to get the most coverage possible. If we cannot work with your insurance company, we will help you every step of the way and put you in touch with the services you need. To learn more about how we can help, call us today.

[1] The White House. (2014). Office of National Drug Control Policy. Substance Abuse and the Affordable Care Act. Retrieved May 10, 2016 from https://www.whitehouse.gov/ondcp/healthcare.

[2] Volkow, Nora D. (2014). America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. National Institute on Drug Abuse. Retrieved May 10, 2016 from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse.

[3] Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Retrieved May 10, 2016 from http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf.

[4] Substance Abuse and Mental Health Services Administration. (2016). Co-occurring disorders. Retrieved May 10, 2016 from http://www.samhsa.gov/disorders/co-occurring.

[5] Cigna Standards and Guidelines. (2015). Medical Necessity Criteria. For Treatment of Behavioral Health and Substance Use Disorders. Retrieved May 10, 2016 from http://apps.cignabehavioral.com/web/basicsite/media/consumer/educationAndResourceCenter/medicalNecessityCriteria.pdf.