By Robert Lien, MHA
Most people cannot afford to pay cash to get therapy or rehab for conditions like anxiety, depression, bipolar disorder or addiction to alcohol and drugs. The cost can vary from less than $100 an hour to thousands of dollars per day for rehab treatment in Los Angeles and that is why utilizing insurance can help. While many people do not need a 24-hour a day inpatient treatment program, long-term support in an outpatient treatment program is ultimately the most effective way to support people struggling with mental health and addiction. Healthcare insurance policies today have benefits that will help with the cost of outpatient rehab for a variety of conditions that can be ongoing for several months.
Insurance policies can be put into two main categories, PPO or HMO. An HMO policy requires the member to utilize providers within a contracted network, while a PPO insurance policy will allow members to choose providers. From these two categories insurance policies can become very detailed regarding what services are covered and what percentage of the cost members are required to pay out-of-pocket. Mental health benefits may be part of the healthcare insurance policy but actually carved out to a different payor so it is important to take time to look at the details of what is covered in the insurance policy and how those benefits are billed. For example, if someone has Anthem PPO insurance the mental health benefits could actually be through different insurance company like Optum.
Many insurance policies today require members to meet or pay a certain amount out-of-pocket before the insurance starts to pay a percentage of the provider’s rate. For example if the deductible in the policy is $3,000 that means the member must pay $3,000 out of pocket before the insurance will agree to pay a certain percentage of the provider’s rate which then leaves the person seeking help to pay their portion of the providers fee. It is important to note that insurance will typically not pay 100% of the provider’s fee until the out-of-pocket maximum is reached and that number like the deductible can vary depending on the insurance policy. Once an out-of-pocket maximum is reached the insurance company will then not require their member to provide any more out-of-pocket funds.
Insurance coverage of rehab services for mental health conditions and addiction are typically approved on what’s called medical necessity. In plain terms the insurance will not pay for services that are not appropriate. For example, a person with a sprained ankle would not meet medical necessity for the intensive care unit at a hospital. If someone does not have a diagnosable condition such as anxiety, depression, substance use disorder there is no reason for the insurance to pay for that service. Therefore, it is important that the facility provides accurate updated clinical assessments, diagnosis and progress reports regarding the person’s treatment plan, along with attendance and progress towards treatment goals to the insurance company for review. At any time insurance may deny coverage based on lack of medical necessity or as the person is progressing and doing well in treatment. There is no rubber stamp for 30, 60 or 90 days of treatment at any given level of care. The level of care, (i.e. detox, residential inpatient, partial hospitalization PHP or intensive outpatient IOP) is also determined by medical necessity criteria. The level of care determination is a team effort that typically includes a medical doctor, psychiatrist, therapist, clinicians and the insurance company. Depending on what is determined as the starting level of care clients will typically step down as they are doing well and meeting treatment goals. Occasionally, clients will need to step up to a more intensive level of care if they are not staying sober or are struggling with stabilizing on psychiatric medications among many other factors.
It is important to understand and communicate what type of insurance benefit approval you may be receiving and how many days are being authorized for rehab. Understanding this helps with planning for next steps in the level of care along with seeking additional services and support that may be available within the insurance benefits or outside of the insurance benefits to maintain and continue to make progress. It is not uncommon to utilize a variety of professionals in the course of treatment and making the most out of the insurance benefits is a significant financial relief.
Prior to admission at CAST Centers our insurance specialist will call to speak with an insurance representative to verify that there are benefits that can be used for rehab and then also to calculate if there is any out-of-pocket cost required to meet a deductible, copay, out-of-pocket maximum or other fees. Having this information prior to admission allows our clients to comfortably begin treatment focusing on themselves rather than worrying about any unexpected costs. Make a free call to CAST Centers Admission Department today at 866-283-9885 to see if your Anthem Blue Cross, Cigna PPO, Aetna PPO or GEHA insurance can help you get the help you are seeking.