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If you or your loved one has decided to seek treatment for a condition like substance use disorder, congratulations. You have a long road in front of you, but at least you have made the most important step of the journey. The next step is finding out which facility you will use and how you will pay.
It is easy to get lost and muddled in the bureaucratic swamp of insurance. In fact, this frustration could be so unnerving that someone may give up seeking treatment for a mental health issue. Here, we’ll explain everything you need to know about getting the most out of your insurance plan for mental health issues.
Mental wellness therapy has become a booming industry over the past few decades. As a result, almost every insurance company offers some coverage for mental health. The devil is in the details. A wide discrepancy exists in the amount of benefits that health insurers pay and the out-of-pocket costs an insured will be forced to pay. Without the proper guidance, it is too easy to miss out on coverage an insured might be paying for.
The Marketplace is a website where individuals can peruse various health care plans offered through the Affordable Care Act (ACA). Most people’s mental health became a bit fractured during the Coronavirus. Overdoses surged to unprecedented levels. Massive layoffs and unspeakable deaths, resulted in historic levels of depression. Unable to go outside, countless people spent months in their living rooms. ACA recognized that during such a crisis, mental health treatment was just as important as physical health treatment.
The good news is that all plans offered on the Marketplace cover mental health and substance abuse treatment. The bad news is the level of coverage offered on some of these plans could be lacking. In addition, some health plans might offer mental health coverage, but then unlawfully deny such claims.
Most insurance plans are usually complicated to read. They are vague at best and indecipherable at worst. When it comes to insurance, a mental health disorder is different from a physical injury. For starters, a broken leg is unquestionably an injury that must be treated. An addiction, a depression, a sleep disorder could be more difficult to diagnose, hence easier for an insurance company to deny coverage.
Sometimes, insurance plans word their plans, so that available coverage is much harder to actually attain. An insurance plan could contain requirements that a plan member must meet in order to qualify for mental health coverage. For example, in Wit et al., v. United Behavioral Health, a class-action California lawsuit, the plaintiffs sued the defendant’s benefit administrator, because of its failure to provide treatment for mental health or substance abuse. The plaintiff’s claims were denied, according to defendant United Behavioral Health, because they failed to meet a level of care or coverage determination thresholds.
The judge ruled that the defendant’s strategy to develop such coverage determinations, were influenced by the defendant’s financial interest.
With all insurance plans being forced by ACA to expand their coverage, it is important for people to understand what they get and don’t get with their policy. A consultation with a trained professional is imperative.
The ACA was passed in 2010 in an attempt to make health care affordable and accessible to every American. Under ACA, in order for a health insurance plan to be available on its Marketplace, the plan must meet the Marketplace Minimum Essential Coverage Standards. One of these requirements is that the plan must carry mental health coverage. As a result, someone who finds a plan on the Marketplace can be confident that it carries mental health insurance.
Before the implementation of ACA, individual and family health insurance plans were not required to carry mental health coverage. Back in those days, someone with a pre-existing condition, say depression, could be denied coverage. Such a situation would make it near impossible for people with mental health disorders, including substance abuse, to find insurance coverage at an affordable price.
Behavioral therapy aims to change potentially unhealthy or self-destructive behavior. The following behavioral treatment is available on all plans on the Marketplace.
Details of the substance abuse treatment offered under Marketplace plans is illustrated below. But substance abuse disorder is so complicated that insurers must offer the full spectrum of substance abuse disorder treatment services. To offer some services but not others, would make the plan ineffective.
Treatment at a psychiatric facility would be covered.
Insurance companies and self-insured companies may outsource their claims processing TPAs. UMR is the nation’s biggest TPA. It is a UnitedHealthcare Company. An employer may get UMR insurance to ensure that claims are paid quickly and efficiently. UMR insurance coverage strives to ensure that people receive the advantages of their healthcare plans. UMR does not provide health insurance. However, UMR helps individuals get the medical treatment that they require.
While UMR insurance will not directly provide treatment, a UMR representative will negotiate the costs of mental health services between health care providers and the insured. Find out if your insurance or medical facility works with UMR. Rock Recovery Center, for example, is an accredited substance abuse program that is in-network with UMR. UMR insurance coverage could be the difference between a coverage and a denial.
A dual diagnosis, also known as co-occurring disorders, is more common than people think. A person who has a substance abuse disorder as well as a mental health disorder would have a dual diagnosis. How often are addictions the result of a mental problem? Almost all the time.
What would substance abuse treatment do for the four unfortunate examples above? Not much, because substance abuse is not the individual’s main problem. They may stop using for some time. But if the mental issue still remains, of course they will relapse.
Consider the chicken or the egg paradigm: What came first, the addiction or the mental disorder? The only way to cure such a patient is if their substance use disorder is treated along with their mental health issues.
A patient with dual diagnosis disorder will require more complicated services during rehab and hence, may experience less than desirable results at the end. As a result, it is imperative that someone with dual diagnosis disorder be treated appropriately. Without the proper treatment, troubled individuals usually find themselves forced into rehabilitation programs that fail to improve either of their afflictions.
Again, the role of UMR is to guide and educate their clients to appropriate treatment. UMR will work with medical or rehab facilities to locate the best possible treatment and the lowest possible costs for the individual patient. Once a treatment has been found, the out-of-pocket costs will vary. The insurance company will shoulder a portion of the total amount, and the rest can be paid with a credit card. With some insurance plans, clients will only pay ten to twenty percent of the total amount!
Imagine that you decided to pay for your loved one’s substance abuse treatment. You shell out a small fortune for their detox procedure. After that, the inpatient and outpatient treatment plans are equally expensive. Your loved one is finally finished with treatment. On their way out, the therapist suggests continuing counselling. While you may not want to spend any more money, if your loved one doesn’t continue therapy, every cent you had paid for her treatment could be in vain. All it takes is one relapse, and the whole process needs to revolve again.
The ACA views substance abuse treatment in a similar fashion. Why should an insurance company invest such a tremendous amount of money for a treatment that could be ineffective? As a result, coverage for substance abuse treatment under ACA, is as complete as coverage for a more tangible and physical injury, like a broken limb or a hernia.
For example, these are some of the services covered under insurance policies purchased on the Marketplace:
Remember, before ACA, any addict considering sobriety, could not rely on insurance to cover any of these towering charges. The individual would have to pay for all this treatment on their own.
If this article tells the reader one thing, it is that your insurance policy can become a Pandora’s Box of complications. Especially after the passage of ACA, insurance policies offer a lot more services. The best way to ensure that an individual takes advantage of everything their policy offers is by having UMR insurance coverage. Make sure that your provider is in-network with UMR.
In-network health care providers work with certain insurance companies to accept certain negotiated rates. Out-of-network health care providers will not accept such lowered rates. As a result, if a facility does not have UMR in their network, the client will have to pay a much higher cost to use their services, or the person will not use the services at all. Rock Recovery is in-network with UMR.
Call Rock Recovery to find out how your insurance can best suit your mental health or substance use disorder treatment.