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Does Private Insurance Cover Alcohol Rehab in Ohio?
Private health plans in Ohio sometimes cover treatment for substance use disorders and alcohol addiction rehab, but not always.
Some private insurance plans require prior authorization for coverage for inpatient or residential substance abuse treatment programs. Prior authorization is an approval process used by health insurers and other payers to ensure that health care services being provided to a member/patient are medically necessary, appropriate for the condition/diagnosis, and consistent with standards of good practice.
The Affordable Care Act requires non-grandfathered individual and small group plans in the Marketplace to provide coverage for mental health/substance use disorder benefits as an essential health benefit.
A number of insurance plans cover treatment for substance use disorders. Whether or not private health insurance covers alcohol rehab depends on the plan details.
It's important to review the terms and conditions of the insurance policy to determine the extent of coverage and any applicable deductibles or out-of-pocket expenses.
If you're having problems getting coverage you think is owed, check if you have an appeal process with your insurance company.
02 / 07
Ohio Mental Health and Addiction Parity Rules
Ohio Revised Code and federal MHPAEA together shape Ohio's rules for parity.
Financial requirements for addiction benefits may be no more restrictive than the financial requirements for medical/surgical benefits.
Quantitative treatment limitations (e.g., number of visits or days of coverage) for addiction benefits may be no more restrictive than the quantitative treatment limitations for medical/surgical benefits.
Non-quantitative treatment limitations (e.g., prior authorization, utilization review, step therapy) for addiction benefits may be no more restrictive than the non-quantitative treatment limitations for medical/surgical benefits.
Insurers cannot impose treatment limitations or financial requirements that are more restrictive for mental health and substance use disorder benefits than they are for medical/surgical benefits.
You are responsible for paying any deductible, copayments, coinsurance, or other out-of-pocket expenses that your insurance requires you to pay.
03 / 07
Federal Parity Under MHPAEA
The Paul Wellstone and Pete Domenici Act of 2008 (MHPAEA) requires health plans that offer both mental health or substance abuse disorder benefits and medical/surgical benefits to ensure that the financial requirements (such as copays, deductibles, out-of-pocket maximums) and treatment limitations applied to mental health/substance abuse coverage are no more restrictive than those applied to substantially all medical/surgical benefits.
MHPAEA requires parity between the financial requirements and treatment limitations imposed on MH/SUD benefits and those for medical/surgical benefits.
MHPAEA prohibits group health plans and insurance issuers offering group coverage from imposing more restrictive financial requirements or treatment limitations on mental health and substance use disorder benefits than on medical/surgical benefits.
Nonquantitative limits include medical management and utilization review techniques, such as prior authorization, step therapy protocols, and formularies that limit coverage for certain drugs. For nonquantitative limits, the regulation states that they must be comparable to those used for medical/surgical benefits.
Medical Management Techniques – The use of non-quantitative treatment limitations for mental health and substance abuse disorder treatment is allowed as long as these techniques are comparable to and no more restrictive than the techniques used for medical and surgical treatments. This means a health plan may impose restrictions on coverage but it must be consistent with the way those same restrictions are applied to other healthcare services.
Prior Authorization – Plans can set up prior authorization requirements. However, under the parity law, these prior authorizations should not be more stringent than they are for other types of care.
Step Therapy – Step therapy is a restriction on coverage if a health plan or insurance company requires a patient to try lower cost treatments before he or she can get access to higher-cost treatments. However, under the parity law, step therapy cannot be more restrictive than how step therapy is used for physical ailments.
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Checking Benefits Before Admission
Before admission, checking a plan's Summary of Benefits and Coverage (SBC) helps people know their financial obligations before they enter the program.
Confirming network status and prior-authorization rules before your loved one enters treatment can help you avoid unexpected bills later on.
A person's insurance may require a referral from their primary-care physician or proof of a diagnosis before it will cover outpatient services.
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Authorization Reviews and Medical Necessity
Prior authorization and medical-necessity review act as gatekeeping. The process is a way to make sure the services provided are medically necessary and appropriate given the patient’s condition, as well as ensure that they will help them achieve their individual treatment goals. In addition to these reviews, some plans may have limitations for what type of facility or providers a patient can receive care from.
Pre-service claims ask for approval before a medical care service is provided. They generally are used when the health plan has rules about how a particular type of service must be provided (e.g., it requires prior authorization or pre-approval).
A pre-authorization requirement is an NQTL.
The process and criteria used to determine whether treatment or services are medically necessary must be comparable to those used for medical/surgical benefits, and applied no more stringently.
Medical necessity denials still need a written description explaining why your care is not medically necessary. This is the same requirement for medical/surgical claims that have been denied by the insurance company.
06 / 07
Appealing a Denial
After a written denial notice arrives, the next step is to file an appeal.
Appeal letters should contain the following information:
- Your name and plan identification number;
- The name of your health plan or insurer;
- A description of the denied service(s), including the dates, names of providers, and reason for each request;
- Why you think the appeal should be granted; and
- Any other relevant information that supports your case.
An internal appeal gives the plan a second look at whether it denied your claim correctly. The first step in an internal appeal is to write a letter to your plan asking that it review and reconsider its denial.
Your letter should include:
- A description of why you disagree with the plan's decision;
- Information about your medical condition since the initial claim was filed; and
- Evidence from your health care provider, including a statement describing why the services are medically necessary.
A new reviewer must examine the full appeal file and all relevant material, including any new or additional information provided by you or your doctor or other health care provider. You or your physician can submit whatever information you feel is relevant to support your case. For example, if your plan denied your claim because it said the treatment was not medically necessary or experimental, you could include with your appeal a letter from your treating physician explaining why the procedure was necessary.
After you file an appeal, the plan administrator will review your claim again. The person assigned to review your appeal must be someone who is different than the person who made the original decision to deny your claim. If the plan administrator upholds their initial denial, they must tell you in writing why it was denied and what your next steps are.
If you are dissatisfied with the second level appeal determination, you have the right to request an external review within 4 months of receiving that determination.
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Filing a Complaint With the Department of Insurance
Consumers who cannot resolve a parity dispute directly with their insurer can file a complaint with ODI.
You have many options when it comes to filing an insurance-related complaint with the Ohio Department of Insurance. The process depends on what type of insurance-related issue you are experiencing.
If you have a private insurance policy (individual policy, or a group plan through an employer) that covers mental health and substance abuse treatment and your request for coverage has been denied, you can file a complaint with the Department of Insurance.
If you are unable to resolve an issue with your health plan through your health plan's internal appeals process, or if your health plan does not have an internal appeals process, or if you want further assistance in resolving an issue with your health plan, you may file a complaint with the Department of Insurance.
When filing a complaint, consumers should include as much supporting documentation as possible. When claiming that coverage was denied or delayed, the consumer should also include copies of any correspondence with the insurer about that decision.