Typically, the way insurance works is that a person signs up for a healthcare plan and pays a monthly premium. Insurance can be bought on the federal Marketplace or from insurance companies directly during an open enrollment period. Different providers may be available, depending on where a person resides.
Most insurance plans have deductibles, or amounts that a person must reach, before insurance coverage kicks in. Insurance will then pay a percentage of the services rendered while the individual is responsible for the remaining amount. For example, if someone has a deductible of $500 and insurance pays out at 80 percent over that, after $500 is paid out of pocket for medical expenses, the insurance company will pay 80 percent of the remaining balance while the individual is responsible for 20 percent of the costs. This is called coinsurance.
Policies will also generally have an annual out-of-pocket limit, or maximum, after which the insurer will pay 100 percent of all covered medical costs. At the time services are provided, individuals may also be required to pay a copay, which is separate from deductible and coinsurance amounts. Copays are typically low in dollar amount.
Insurance plans often come in differing levels of coverage, such as Bronze, Silver, Gold, and sometimes Platinum. Generally speaking, Bronze-level plans have the lowest monthly premiums and highest deductible and potential out-of-pocket costs while Platinum plans offer the reverse.
Within each specific plan, the type of coverage and services that are covered can vary. Different plans may require individuals to receive care at specific treatment facilities or obtain a referral before specialty services (like those related to addiction or mental health concerns) can be rendered. Insurance plans may only cover services performed by an “in-network” provider as well. Healthcare providers often work directly with insurance providers to offer discounted rates on services provided to members. These providers are then considered to be in-network for these insurance policies. Other plans may allow its members to obtain services from providers that are considered “out-of-network,” however these services generally cost more and may be covered at a lower percentage.
A PPO (Preferred Provider Organization) plan allows individuals to receive care from out-of-network providers without a referral for a higher cost while providing lower costs for services obtained from in-network providers. An HMO (Health Maintenance Organization) requires individuals to remain in-network for medical services (except in the case of emergencies) and often requires members to work or live within a specific services area. POS (Point of Service) insurance plans provide discounted rates for in-network providers and require a referral for specialty services.
Different states and insurance companies will have different policies, coverage types, and plans available to members.
Click below to learn about some of the major insurance providers with policies that may cover drug treatment or ancillary services.
Insurance Companies Explained
There are hundreds of different health insurance providers offering coverage within the United States, and each has a variety of plans and options to choose from. Below are some of the most common providers and general information on them:
- Aetna Insurance: Covering over 23 million members in 2016, Aetna offers an array of insurance plans and coverage types provided by a wide range of treatment providers and innovative services.
- Anthem: In partnership with Blue Cross Blue Shield, Anthem Insurance is the second biggest health-plan-owned behavioral health company, providing its more than 13 million members with access to a large network of behavioral health providers.
- Blue Cross Blue Shield (BCBS): With over 100 million members and the highest rate of specialists, hospitals, and doctors contracted by a health insurance company in the United States (over 90 percent), BCBS provides insurance coverage for members in all 50 states.
- Cigna: A health services company with a global reach, Cigna has relationships with over 1 million service providers, clinics, facilities, and healthcare professionals around the world to provide its members with comprehensive medical care and highly rated insurance coverage.
- Healthnet: With comprehensive coverage provided in all 50 states, Healthnet offers a ProviderSearch tool to help members find contracted specialists, hospitals, and doctors in their local area. The company strives to enhance the wellbeing of its members.
- Humana: Offering a wide range of health insurance plans for families, individuals, and employers, Humana provides budget-friendly plans for people from all walks of life with innovative services and a commitment to overall health and wellness for those it serves.
- Kaiser Permanente: Through personalized care and dedication to its members, Kaiser Permanente provides quality healthcare services and insurance coverage as one of the biggest not-for-profit health plans in the United States.
- Molina Healthcare: A multi-state healthcare organization, Molina Healthcare is a Fortune 500 company offering health management solutions to its millions of members with a strong focus on preventative medicine.
- Asuris Northwest Health: A not-for profit healthcare company, Asuris Northwest Health offers a strong leadership and community roots as well as many insurance plans to choose from to improve the overall health and wellness of its members.
- Tricare: Serving United States active duty military members, their families, and retirees, Tricare provides healthcare and comprehensive coverage that includes all of the essential health benefits and specialty services, and offers 11 different plan options to choose from.
- UnitedHealth: A comprehensive and diversified health company, UnitedHealth Group prides itself on innovation, adaptation to an ever changing market, and helping people to live healthy lives. The company serves people’s healthcare needs in all 50 states with over 30,000 nurses and doctors within the workforce.
Individuals who require subsidization, or who cannot afford health insurance and meet specific criteria, may be eligible for federal Medicare coverage offered in partnership with one of the above insurance providers. Be sure to check with the health insurance provider directly for more information on Medicare coverage, local healthcare plans, covered services, and any restrictions or limitations that may exist.
Insurance for Behavioral Health Services
The Affordable Care Act (ACA) ensures that behavioral health services are covered under any health insurance plan sold on the federal Marketplace. Mental health and addiction issues are included as “essential health benefits” that are required to be covered by insurance the same way that other medical and surgical procedures are. Covered services can include:
- Detox services
- Crisis services
- Inpatient treatment
- Outpatient treatment
- Residential treatment
- Therapy and counseling
- Prescription medications
- Community-based programs
- Co-occurring disorders treatment
To be able to use insurance to help pay for addiction or mental health treatment, a person must often prove medical necessity. This means that coverage is only offered if it is deemed medically necessary. Individuals may need to visit their primary care provider (PCP) in order to obtain a referral for these specialty services.
Many plans require that a person first attempt an outpatient addiction treatment program, and be unsuccessful, before the insurer will provide coverage for a more comprehensive inpatient program. Insurance plans may provide coverage for a preset amount of time in a treatment program, for a certain number of therapy or counseling sessions in a calendar year, or up to a certain monetary amount annually. Plans vary on what is covered, how much is covered, and what restrictions and exclusions may apply.
People may be required to receive treatment services at specific facilities and treatment centers in order for coverage to apply. Different states have variable rules regarding insurance policies and coverage for behavioral health services as well.
Addiction treatment facilities have trained staff on site to help individuals navigate and maximize their insurance coverage.