Can I Get Insurance Coverage for an Injury-Caused Addiction?
Entering treatment often means overcoming obstacles. For some figuring out how to pay for rehab tops the list even though allowing an addiction to continue is far more costly. Financial issues may be one factor that explains one shocking statistic discovered by the Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health. Of the 23.5 million persons age 12 or older who needed treatment for an illicit drug or alcohol abuse problem in 2009, only 2.6 million, which is just 11.2%, received it at a specialty facility.
The key to removing financial barriers to recovery is to understand the complexities of insurance coverage. For individuals who become addicted as the result of an injury-caused addiction, getting the right information is even more important.
Parity Law: Your Legal Rights
Millions of Americans with substance use disorders do not have adequate insurance protection against the costs of treatment for mental and substance use disorders. When an accident instigates an addiction, the negative financial consequences of this can be especially staggering. Prior to Mental Health Parity and Addiction Equity Act (MHPAEA) and similar legislation, insurers were not required to cover mental health care limiting access to rehab. Today the MHPAEA makes it easier for people to get the care they need.
The MHPAEA prohibits certain discriminatory practices that limit insurance coverage for behavioral health treatment and services. According to its guidelines insurance plans that cover substance use disorders are required to offer coverage for those services that is equally generous as the coverage for medical/surgical conditions. This requirement applies to the following:
- Co-pays, coinsurance and out-of-pocket maximums
- Limitations on services utilization such as limits on the number of inpatient days or outpatient visits that are covered
- The use of care management tools
- Coverage for out-of-network providers
- Criteria for medical necessity determinations
Coverage that the MHPAEA does not require insurance plans to offer includes the following:
- Coverage for substance use disorders in general
- Coverage for specific substance use disorders
- Coverage for specific treatments or services for substance use disorders
Insurance companies do not consider the cause of an addiction when determining benefits. Rather they approve or reject a claim for treatment based on the principles of medical necessity. According to the American Society of Addiction Medicine (ASAM), several criteria that prove a service is medically necessary include the following:
- The requested treatment services are required to diagnose or treat a suspected or identified illness or condition.
- Scientific evidence proves that the requested treatment is effective for the condition.
- The requested treatment is required for more than just the convenience of the requester or provider (e.g. you might find it more comfortable to go away to rehab, but unless you can prove that you need it for a medical reason, you will likely get coverage only for outpatient treatment).
Meeting the following preconditions generally results in a claim approval for residential treatment:
- Your withdrawal symptoms can be managed at the requested level of care.
- You are cognitively able to participate in a treatment program and have no other medical problems which preclude your ability to participate.
- You show evidence that you want treatment and are motivated to work toward recovery.
Most plans require that you meet at least one of the following criteria:
- The severity of your self-harm or risk taking behaviors present a serious threat to yourself or to others, and these self-harm or risk taking behaviors can’t be effectively managed outside of a 24 hour facility.
- You have acute medical problems that make it difficult or impossible for you to stay abstinent outside of a residential environment
- Your substance abuse is causing severe problems in at least two domains of life such as school, work, family, social relationships, or physical health.
- There is evidence that a lower level of care wouldn’t help such as previous attempts within the last 3 months at a lower level of care like an intensive outpatient program.
- There is evidence that unless you get residential treatment your condition is going to continue to worsen to the point where you’ll probably need a more serious level of care like hospitalization.
- There is evidence that residential treatment should help to ameliorate symptoms.
- Your current living arrangements are dysfunctional and endanger your recovery progress, and there are no other clinically appropriate or available living arrangements.
Although the ASAM identifies only these three core components, most insurance companies add a fourth component to the decision-making process that the requested treatment is not more costly than any other treatment that is as likely to produce an equivalent result.
Professional Treatment: Your Insurance Guide and Advocate
Professional recovery centers usually offer free help determining coverage and benefits. Information they may request from a caller inquiring about treatment includes the following:
- Is detox needed?
- Have you attempted outpatient treatment?
- What is your desired length of stay?
It is important to keep in mind that this parity laws may not apply to smaller health insurance companies or individual insurance plans.
Recovery from Addiction
If you or someone you love struggles with substance abuse, help is available. Admissions coordinators at our toll-free, 24 hour helpline can guide you to wellness. You don’t have to feel alone when help is just one phone call away. Start your recovery now.