PPO Insurance Coverage for Alcohol Rehab

As a result of the 2010 passage of the Patient Protection and Affordable Care Act (most often referred to as the ACA or Obamacare), insurance providers must offer essential health benefits as part of their overall package of services. Essential health benefits have been previously defined as services, such as laboratory services, emergency services, behavioral health treatments, mental health treatment, pediatric care, vision care, etc., by the National Academy of Medicine. Previous legislation requires that insurance companies provide the same level of benefits for behavioral health services as they do for primary care services; this is a result of the 2008 Mental Health Parity and Addiction Equity Act.

The passage of Obamacare amended all this previous legislation to make sure that both group insurers and private insurance companies provide all of these services. Even though the current administration is working to repeal many of the statutes associated with the Affordable Care Act, it is highly doubtful that all coverage for the treatment of any substance use disorder, including alcoholism, will be removed from the platforms of most reputable insurance companies. Thus, anyone’s private insurance has some benefits associated with the treatment of an alcohol use disorder.

What Does PPO Insurance Cover?

Because there are so many different plans provided by major insurance providers, and there are so many different stipulations in insurance policies, the exact amount of coverage one has for the treatment of an alcohol use disorder can be quite variable.

• Detox: Medical detox services are covered to some extent under nearly every policy. The key to getting coverage is for the referring physician to demonstrate medical necessity (described in a little more detail below). Most insurance companies will cover inpatient and outpatient withdrawal management services to a large extent. What may not be covered are services that are not necessary in the treatment of withdrawal symptoms or that do not have empirical evidence that they are useful in the treatment of withdrawal symptoms, such as certain types of therapies (e.g., acupuncture, ultra-rapid or rapid detox, etc.). Other services, such as housekeeping, recreational activities, and other non-therapeutic activities, may not be covered under a particular policy.
• Other inpatient treatment: Depending on the referral, other inpatient services may be covered under one’s policy. Again, the notion of medical necessity must be fulfilled for inpatient treatment services to be covered, and certain services that are not deemed to be medically appropriate or necessary may not be covered. Emergency services often include inpatient treatment services.
• Residential treatment: Residential treatment services are often covered to some extent under private insurance. Again, the concept of medical necessity must often be satisfied by the referring physician.
• Outpatient treatment: Outpatient treatment services are covered to some extent under nearly every insurance policy. This includes therapy, medications, and other services that have an empirical basis for their use in the treatment of alcohol use disorders.
• Medications: The medications that the individual is prescribed and that are used directly in the treatment of the person’s alcohol use disorder or some other identified medical or psychiatric condition are typically covered to some extent under most insurance policies. This will vary from policy to policy.
• Therapy: Psychotherapy services, including individual and group therapy, other therapies directly related to the treatment of the person’s alcohol use disorder, counseling for substance abuse, etc., are covered to some extent under the individual’s private insurance policy.

These are certain issues to consider when it comes to insurance coverage.

• Copays, deductibles, and out-of-pocket expenses: Most private insurance policies have stipulations that require that the policyholder absorb some of the cost of their treatment. Copays, deductibles, and other out-of-pocket expenses are expected at some level for most individuals receiving treatment for an alcohol use disorder. Most policies do not cover the entire cost of every intervention. It is a good idea to know exactly what is expected from the policyholder and what is expected from the service provider before committing to treatment.
• The concept of medical necessity: As mentioned above, in many cases, insurance companies may require a demonstration of medical necessity for a particular service to be covered. What this means is that the treatment provided is deemed by research evidence that it is required in the specific case and that some other form of less expensive treatment will not serve the needs of the individual just as well. For instance, someone who is undergoing moderate to severe withdrawal from alcohol requires treatment for their withdrawal symptoms (a physician-assisted withdrawal management program). There is no less expensive alternative that can ensure the safety and recovery of the individual in this case.Medical necessity is often an issue for inpatient versus outpatient admissions, certain types of medications, and specific types of expensive treatments. It is typically not a requirement for services like standard substance use disorder therapy, recognized medications in the treatment of alcohol abuse, etc., because many of these interventions have been deemed medically necessary for treatment due to research evidence.
• Research evidence to justify the use of the treatment: The use of treatments that do not have adequate research evidence to justify their effectiveness may not be covered under most insurance policies. Standards accepted by Medicare are typically followed by many insurance companies. For instance, techniques like rapid detox and ultra rapid detox are not covered by most insurance companies because they do not have sufficient empirical evidence to justify their use (research studies have not demonstrated effectiveness for them). Acupuncture is another intervention that is not often covered by insurance companies in the treatment of substance use disorders because there is not sufficient empirical evidence that justifies its effectiveness. There are many others. One should check with their provider to find out what is covered and what is not.

How Do I Verify My Insurance Coverage?

Contact your insurance company’s customer service department to find out if the type of treatment you are seeking for alcoholism treatment is covered under the policy. You can also read your policy to understand exactly what is and isn’t covered; however, some people find the language in their insurance policies confusing. Again, this is where the company’s customer service department can be useful in helping to understand the benefits and limits of coverage. It is important to remember that insurance policies have quite a bit of variation from company to company and even from policy to policy within the same insurance provider.

An alternative approach would be to get in contact with the treatment provider you wish to use, talk to their intake personnel, and have them contact your insurance provider to discuss what services are covered, to what extent they are covered, and what services may not be covered. Treatment providers are very thorough in determining what services are covered by a policy.

When considering very expensive treatments, such as inpatient withdrawal management programs, make sure that a physician referral for that type of treatment is provided to your insurance company. Referrals made by medical doctors carry far more weight than referrals made by therapists, social workers, case managers, etc. Insurance companies are far more likely to honor the requests of a physician than those made by other treatment providers.