Insurance language is confusing, and it is stressful to sort out while someone needs care. Here is what the terms mean for addiction treatment, and what to ask.
Plans have to cover it
Under federal parity law, most health plans that cover mental health and substance use treatment cannot make that coverage more restrictive than their medical and surgical coverage. That applies to copays, visit limits, and prior authorization rules. Medicaid covers substance use treatment in both Maryland and Pennsylvania.
The terms that change your bill
What to ask before you start
- Is this program in-network for my specific plan?
- How much of my deductible and out-of-pocket maximum have I already met this year?
- Does this level of care need prior authorization, and who requests it?
- What will I owe per day or per week, and is there a payment plan?
P2H verifies your benefits before treatment starts and gives you an out-of-pocket figure in writing.
If a claim is denied
You have the right to appeal. Ask for the denial in writing and the clinical criteria used. Programs can often request a peer-to-peer review with the plan's reviewer. If internal appeals fail, you can request an external review through your state.
General information, not medical advice. In a crisis, call or text 988. In an emergency, call 911.