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Are Insurances Facing the Cost of Opiate Treatment?

Typically, the cost of opiate treatment is borne by the customer—the person who seeks help for addiction treatment. That makes it a hard row to hoe for someone who wants help, because opiate treatment is not cheap.

Until recently insurance companies unilaterally have denied any responsibility to pay for the cost of opiate treatment. The Affordable Care Act promised to mandate insurance coverage of addiction treatment, but the insurance companies always find ways to wiggle out of paying. They have said they will pay if a review of clinical services indicates a need for treatment, but then they fail to approve the need after reviewing the circumstances and services.

Typically most private insurances will, in fact, pay for detox at an inpatient facility. This does not refer to residential substance abuse treatment or opiate treatment. It means that if a person is admitted to a hospital for alcohol or benzodiazepine withdrawal, the insurance will pay for their short stay in the hospital. The only reason they pay for that is because alcohol and benzo detox can be fatal if not supervised. Those kinds of detoxes often cause the patient to go into seizures that can lead to death. Detox from heroin is not dangerous; although you might feel like you are going to die, you won’t. But once the patient completes a detox from the alcohol or benzos, he is left on his own to pay for opiate treatment.

However, increasing numbers of state Medicaid programs offer coverage for administration of methadone or buprenorphine, and they will even pay for the cost of the individual therapy sessions or group therapy that you undertake. Those therapy sessions are important so that you can deal with your reasons for becoming addicted in the first place and become educated about the nature of addiction.

Most methadone programs in California will bill Medi-Cal or Kaiser Permanente patients directly. Otherwise the patient pays up front. Some insurances will reimburse the patient if he submits invoices for payment—or they will pay for at least part of the opiate treatment—but many people do not know how to go about submitting their invoices for reimbursement.

Private insurance companies also have limits on the methadone clinic staff whom they recognize as credentialed individuals, that is, doctors or counselors who can bill for services. For example, a licensed independent social worker may be able to bill for an outpatient therapy session, but a mental health counselor without a license cannot bill. Some insurances will only pay for opiate treatment on the days when you actually see the doctor—but even that is something toward the cost of treatment.

Again, it’s important for the facility to have their eligible staff credentialed to participate in your insurance company’s network. Call your insurance company using the number on the back of your card and ask about providers for behavioral health services, including intensive outpatient programs or “IOP.” Anything you can get your insurance to pay for will help you out, even if it won’t pay for your actual medication. Ask the insurance company representative where you can get forms to submit your invoices for reimbursement—they are usually available on the insurance company website.

You can also call your county’s mental health and addiction treatment services board to see if there are local methadone treatment programs that partially subsidize or use a sliding scale to offset the cost of opiate treatment. If you are involved with the courts because of your addiction, the cost of your opiate treatment might be paid by the county TASC program.

A Few Bright Promises for Opiate Treatment…

The journal Addiction Professional recently reported on services funded by the State of Connecticut at a facility called Silver Hill Hospital. Silver Hill has opened an opiate treatment program that includes intensive outpatient therapy, family therapy, and recovery support extended beyond IOP for a year. Methadone or Suboxone therapy is not required but for those who want it, it’s covered. All of these phases of treatment are essential for the person who is serious about opiate treatment.

There are other promising stories surfacing. A case manager at an opiate treatment facility dealt with a young man who lived at home and was covered by his parents’ insurance, which would not pay for treatment. However, with his continued use of heroin, they kicked him out. She helped him submit an application for Medicaid accompanied by a letter stating that although he had been covered by his parents’ insurance, he was rendered homeless because of his addiction, and the Medicaid caseworker granted him medical coverage.

A practice manager for a large multi-specialty addiction treatment group in Ohio reports an interesting development when she contracted with a private insurance company to pay for the cost of residential services. The contract she signed with the company included a rate payable for methadone treatment, even though methadone therapy is rarely a part of residential treatment. She is also contracting with a large employer in the area who self-insures its employees’ healthcare, and the company’s benefits administrator has likewise opted to include methadone therapy in the contract. Slowly, then, the insurance companies may be opening their eyes to the need for medication-assisted treatment programs.

Nevertheless, People Are Dying

Despite these promising steps forward, people are still dying because they cannot pay for treatment. Meghan Barr of Business Insider told the story last year of 26-year-old Salvatore Marchese who struggled with the need for opiate treatment. He couldn’t afford to pay for treatment and he couldn’t stand the withdrawal.

Initially a hospital refused to admit him during heroin withdrawal, because it’s not fatal. His sister then lied and said he was also using alcohol, and so his insurance paid for 17 days of inpatient detox. However, when he was discharged, he still could not get into methadone treatment, and three months later he was found dead of an overdose.

Don’t let that be you. Don’t let that be your loved one. Talk with your local opiate treatment program about the cost of treatment, and see if you can pay one week at a time. At least it will get you started while you explore your other options. Make a phone call today.

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