Can You Appeal to Get Your Health Insurance to Cover Rehab?

If you have a significant addiction to drugs or alcohol, your only real chance for survival and recovery is getting treatment for the addiction from a reputable treatment center. Getting treatment is serious enough that you need to do it regardless of the financial burden it may cause. If you have followed the law, you should have healthcare insurance. Why is that applicable to addiction treatment? According to the Affordable Care Act of 2009 (ACA), healthcare insurance providers are required to cover addiction treatment costs the same as they would any other medical condition. In fact, here’s some of the areas the ACA requires insurance companies to provide addiction coverage for;

  • Medical detox, including medications
  • Outpatient and intensive outpatient care
  • Inpatient care – up to 90 days
  • Co-occurring mental health conditions
  • Maintenance addiction medication
  • Follow-up counseling

There is one major caveat to the ACA’s requirement that insurance providers cover addiction treatment costs. Nowhere does the ACA dictate the extent of financial support the insurance company must give. In many cases, the insurance company will go ahead and offer the same extent of coverage as they would for a broken arm or cut foot. In other cases, the insurance company will offer a lower level of financial support, which is allowable so long as the coverage falls within ACA guidelines.

What if Your Insurance Company Doesn’t Adequately Cover Addiction Treatment?

Keep in mind, at least a portion of your addiction treatment costs should be covered by your healthcare insurance provider. It might not be 100% coverage and in that case, you will likely have out-of-pocket costs. Hopefully, the extent of those costs will not serve as a reason for you to not get the level of addiction treatment you want and need.

Do you have the right to appeal the extent of your coverage? The truth is that as long as your insurance company complies with the ACA’s standards, any appeal attempts are likely to fail. However, there are circumstances where an appeal could prove to be worthwhile.

Reluctance to Cover the Aforementioned Required Categories

If you will take a minute to review the list of addiction treatments the insurance company is required to cover to some extent, you might be able to identify a problem within your insurance policy.

There should be very little ambiguity about that list. If your insurance company were to elect to not cover some or all of the costs in one of those areas, you might have cause for appeal. Prior to making such an appeal, you’ll want to confirm your addiction treatment facility used a qualified form of treatment.

This is brought up because some inpatient or outpatient insurance coverage is restricted to standard forms of addiction treatment. It is possible your treatment facility will elect to use a modern treatment modality that doesn’t follow guidelines. You can avoid this problem by coordinating with the treatment center and insurance provider to make sure the treatment facility uses appropriate treatment options.

Disclosure Issues

According to the ACA, insurance providers are required to offer a one-page policy summary to all customers. The summary is required to serve as a snapshot regarding the coverage afforded by the policy.

Should your insurance company not provide said summary, including the extent of addiction coverage that’s available, you might have the basis for an appeal. Most of the time, summary disclosure appeals will involve extent of coverage issues.

The Appeal Process

If you feel you have an appeal-able issue, you have two paths you can pursue. Denial of payment and cancellation of your policy would be typical issues.

The first step in the appeal process should be made directly to the insurance company. They should perform a complete and impartial investigation and provide a final disposition.

If you are unsatisfied with the insurance company’s position, you do have the right to make an external appeal to a government agency. That external government agency will likely be the state insurance commissioner’s office. In many states, determinations by the insurance commissioner are binding.

Whether you have insurance or not, you need to clearly understand you are going to need help for your addiction. In many cases, the treatment center will work with you to find the financial resources you will need to pay for treatment. 

Ready to Make a Change?

We know that overcoming addiction is not easy and requires courage to ask for help. At Woburn Addiction Treatment, our team of professionals has decades of combined experience in helping men, women, and families overcome substance abuse.

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