This is part of Tonic’s Healthcare Guide series. See the other guides here, and find the glossary here. Download the PDF version of this guide here and a find a PDF of the master document here.
Although the Affordable Care Act (ACA) is supposed to guarantee addiction treatment to anyone with Medicaid or private insurance, people with opioid addictions and their loved ones still face a dysfunctional system that can make it very, very hard to get help.
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Here are some tips for getting around some of the biggest insurance roadblocks.
Is rehab the best, most effective treatment for someone addicted to opioids?
The world of treatment for opioid addiction is upside down: The best treatments for cutting relapse and preserving life are stigmatized and relatively cheap, while less successful and more expensive residential approaches are featured as models in the press and on television programs like Celebrity Rehab.
“The layperson still typically assumes that addiction treatment is residential treatment and that’s a misconception,” says Sam Arsenault, director of National Treatment Quality Initiatives for Shatterproof, an addiction advocacy organization. Opioid use disorder (OUD) can often be treated effectively on an outpatient basis, she says, although residential treatment may be appropriate for some.
Regardless of the treatment setting, anyone seeking care needs to know this: methadone and buprenorphine (Suboxone), used long-term and in some cases for life, are the only two treatments proven to cut the overdose death rate by half or more.
Inpatient or outpatient rehabs that don’t permit the use of this medication or only use it short-term do not have this benefit—and these rehabs are less good at reducing relapse. A newer medication, long-acting naltrexone (Vivitrol) may help some, but it doesn’t have the proven, lifesaving results that the two other drugs do.
Consequently, if you or a loved one is seeking care and want the best odds of recovery, choose a program that uses methadone or buprenorphine long-term, not just for a week or two of “detox.”
However, if the person has only been addicted to opioids briefly or has other strong reasons for not wanting to start long-term use of one of these drugs, consider Vivitrol or drug-free programs that provide evidence-based psychological treatments like cognitive behavioral and motivational enhancement therapy. But the safest and most effective approach is to combine voluntary and appropriate psychological treatments with methadone or buprenorphine.
Is therapy also necessary? What about other support?
No, but it’s advisable. For many, a critical part of treatment is addressing problems that may have led to the addiction. At least half of people with any kind of addiction have another mental illness and most have experienced childhood trauma. For opioids, particularly heroin addiction, these rates are even higher: 90 percent have had at least one trauma exposure and a third have post-traumatic stress disorder (PTSD).
Ideally, these issues should be appropriately assessed and treated—if they aren’t, recovery is much less likely. However, if the only step a person is ready to take toward recovery is taking medication, that should be encouraged: Medications offer protection against overdose even if use of other drugs isn’t immediately stopped.
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Also keep in mind that treatment that is warm and welcoming is much more effective than confrontational, coercive, or disrespectful counseling: Avoid authoritarian or humiliating programs. Calling the program and asking them about rules and discipline will usually unmask such providers; if something feels punitive, rigid or cold, avoid it if possible.
Since addiction is often chronic, it’s important to plan for both ongoing care that reduces in intensity as the person recovers and, particularly, social support. This can take many forms: family, friends, 12-step groups, other self-help, gym memberships, volunteer work, church—basically, whatever the person finds most appealing and sustainable and keeps them occupied without substances. Exercise can be especially helpful as the “high” from exercise can help restore the brain’s pleasure and motivation systems—if people engage in activities they actually enjoy. (Note, though, that you don’t have to love every second of it.)
How do I find a provider that’s covered by my insurance?
It’s time to take a good look at your insurance documents and search their website for addiction treatment providers that are covered “in-network,” meaning they will be the least expensive.
“Rather than go through their insurer, many people go to Dr. Google and locate treatment that way,” Arsenault says. “That can result in a higher price tag.” Staying in-network will be cheaper and easier to get covered—go “out-of-network” only if you can’t find care of sufficient quality.
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What does insurance have to cover? Do they cover it without a fight?
This part is tedious but critical. “The great thing about the Affordable Care Act is that addiction treatment [must be] covered,” says Michelle Katz, a healthcare consumer advocate and nurse. The federal “parity” law, which is part of Obamacare, requires that no limits be placed on treatment for addiction and other mental illnesses that aren’t placed on coverage of physical illness. But the devil, of course, is in the details, which will vary from state to state and from insurer to insurer.
Consequently, reading your policy and learning about these details is essential. (You can find the covered benefits on your insurer’s website or in a document you probably stashed in a drawer and forgot about.)
In addition to the specifics on addiction care, the document will also include sections on what are known as “internal” and “external” appeals, or the processes to go through if (and when) a claim is denied.
“Many times, the first time you submit a claim, you will be rejected,” Katz says. You’ll need to know the nature of the appeals processes, which allows you to fight denial of coverage. If you’re denied, immediately demand a review, which will first be done by a doctor who works for the insurance company (internal appeal). If you lose in the internal review, go for an external review, which has to be done by a doctor who isn’t employed by the insurer.
Some insurers have “fail first” policies, which mean that people have to try less-intensive treatment and fail at it before more comprehensive care will be covered. This is less likely to be a barrier to getting medication treatment covered, but it is often used to fight against paying for inpatient care.
Consequently, be sure that inpatient care truly is the best option in your case if you are going to fight for it. For people who aren’t homeless and not living with drug dealers or in other dangerous environments, outpatient treatment can often work just as well. (If you’re convinced that a change of setting is necessary, a new safe living space far from known dealers and drug-involved friends doesn’t necessarily have to be in a treatment program).
Write down what you’re told in phone calls—immediately, so you don’t forget. (In many states, it is legal to record calls without the knowledge of the other party—and many insurers are already recording you as they state in their phone systems.)
Is there a way to avoid getting care denied outright or get appeals approved faster?
As you can see from the above, dealing with insurance coverage for addiction is often a hassle. If you have a primary care doctor who knows you and is familiar with your insurer and the genuine need for treatment, that doctor may be your best weapon in the fight, according to Katz.
What you want to find is someone who knows the specific language to use in documenting the need for care that opens the door to coverage with that particular insurer. “You need to put language in the chart that emphasizes the desperation of the situation,” Katz says, “Ask for expedited approval because it is a life-threatening condition.” Given the overdose crisis affecting people with opioid addictions, this is not an overstatement—but it needs to be stated starkly.
Advocacy groups for families with addiction like Shatterproof and the Partnership for Drug-Free Kids have useful resources and can help connect you with others who’ve been there to help you fight your way through the system.
Depending on the state where you live, the attorney general’s office and the state agency that regulates insurance may also be helpful. Since these officials deal with bad behavior by insurers, they know the relevant state law and how patients can get the benefits they’re owed. The names of the agencies involved vary by state, but searching for “health insurance consumer protection” or “health insurance regulation” and the name of the state should bring them up.
While it’s almost never helpful to be impolite, it’s critical to be persistent. The more you complain and the more you show that you know what should be covered, the harder it is for insurers to deny benefits.
Bombard them with studies (some useful research is linked earlier in this guide) that show what works to fight opioid addiction, call frequently, and let them know you aren’t going to stop until you or your loved one gets the treatment they need to get better. Endless paperwork and slow bureaucracy are huge deterrents to getting your claims paid, but don’t let it stop you.
Are there things I can do now to be ready when someone wants treatment or if there’s a crisis?
Fighting to get the coverage you’re owed can sometimes be a full-time job in itself—and this is hardly what a person with addiction or their family members need to deal with while in crisis or when a person who previously resisted help finally decides to go for it.
Consequently, try to do your research and have as much of the paperwork ready as possible (like medical and insurance records) before there is a crisis or recovery opportunity—either of which is hard enough to manage without having to deal with insurance companies.
Should I also have naloxone?
Regardless of where you or your family member is in the recovery process, keep the overdose antidote naloxone on hand—it’s better to have it and not need it than it is to need it and not have it. Some insurers will cover this medication with no copay and many harm-reduction programs distribute it and train people to use it for free. There’s more info on how to get naloxone here.
What about people who don’t have insurance or their coverage isn’t enough?
Most states have publicly funded treatment programs that are available to the uninsured, and nearly all treatment programs will also work to enroll patients in Medicaid so the facility can get paid for the care. Calling a treatment center that seems like a good fit and asking if this is an option at their facility is generally the best way to find out about these slots. Some private programs also have “scholarships” for people who cannot otherwise afford to attend; again, call and ask.
Be aware, however, that some rehabs and treatment programs will “balance bill” for services that aren’t covered completely; people have been hit by surprise bills for thousands of dollars. Ask about exactly what is covered and what isn’t, especially with regard to “scholarships.”
Further, don’t pay any unexpected bill just because it is sent to you. Call and challenge it, and find out about your specific rights via your attorney general or insurance commissioner’s office. In some states, it’s actually illegal for programs to accept insurance payments and then bill the patient for more than the insurance rate for a given service. Your insurance will send you documents known as an explanation of benefits (EOB), which will spell out how much a provider is allowed to charge for a specific service. If the provider tries to bill you for more than the “allowable amount,” challenge it.
Any final words of wisdom?
America’s medical system is not patient-friendly in general, and it is even less so when it comes to addiction. However, most people with opioid addiction do recover—provided they can avoid overdose. Always have naloxone, try to keep on top of your insurance coverage (both maintaining coverage and fighting for benefits), and reach out to organizations like Shatterproof and The Partnership for Drug Free Kids for support from others who have been there.
It can be a long road—but as someone who is in recovery myself, I can tell you that it is possible and wonderful.
More Tonic Healthcare Guides:
If You Have a Mental Health Issue
Glossary of Health Insurance Terms
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