Can't Get Treatment Through Your Health Insurance Plan?

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Summary

  • Don't let the stigma of addiction prevent you from fighting for insurance coverage for drug and alcohol problems.
  • Most states (43) have laws requiring insurance plans to cover addiction treatment.
  • Prepare by becoming thoroughly familiar with your employee benefits and by being ready to challenge any efforts to deny coverage.

Reflecting a broad, national consensus on this issue, between 1973 and 1995, 43 states and the District of Columbia have enacted laws requiring commercial group health insurance to cover treatment for alcohol and other drug addictions.

During this time period, debate in the state capitals displayed a growing awareness of the horrific toll of untreated addiction on 1 in 4 families as well as its relationship to burgeoning crime rates, hospitalizations and deaths.

Supporting the enactment of these state laws is an ever-growing body of research demonstrating the widespread nature of addiction to drugs and alcohol, the economic cost of untreated addiction to the country (an annual $328 billion a year) and the cost savings available when adequate treatment is provided ($7.00-$12.00 saved for every $1.00 spent).

Despite the enactment of these 43 state laws, today few can access the treatment required by law and paid for by the policy holder. In fact, getting a loved one into treatment for addiction through group health insurance and managed care has become a costly, national nightmare with desperate families reduced to begging for treatment that was already paid for through their insurance plans.

Caught in the bottomless quicksand of denial, people in need of treatment are shifted from insurance to charity or to public funding. Some deteriorate in an ever-downward moving spiral losing health, jobs and destroying families along the way. With the addiction untreated, some fail into other health care problems and hospitalizations, end up on the streets, commit crimes or go to jail. Others, in desperation, take their lives.

How can this be? 43 states have passed laws requiring provision of treatment, the contracts have been written and the premiums have been paid. Why can’t policyholders access addiction treatment required by law?

Enforcement of the state laws has proven to be difficult due to the intense stigma that continues to surround addictive diseases. Families are often desperate for help, yet because of the stigma, few have been willing to challenge the insurance industry. Yet, this is precisely what must happen. Until those denied coverage speak up, agencies charged with enforcement of these provisions of law and contract - will not, cannot act. The agencies must have complaints from subscribers who have been denied their rights.

In this environment, health insurance policyholders must be prepared to fight and use every tool available to hold health plans accountable for the treatment benefits outlined in their employee benefit handbook and under the requirements of state law.

Subscribers must prepare by reading their benefit handbook, by knowing what coverage is provided, knowing the state laws and by holding their health plans accountable. Finally, because of the serious, sometimes fatal nature of this illness, THE SUBSCRIBER MUST NEVER BACK DOWN.

Can't Get Treatment Through Your Health Insurance Plan?

Forty-three states and the District of Columbia require commercial, group health insurance plans, including managed care, to provide coverage for addiction treatment. States without such laws are: Arizona, Georgia, Idaho, Indiana, Iowa, Oklahoma and Wyoming. To obtain information on your state law, please contact the National Alliance for Model State Drug Laws . (Do not use this contact for emergencies. For emergency assistance, please call local emergency numbers.)

Group health insurance plans are required to comply with state laws and any additional coverage that employers may request. However, many health plans have financial incentives to deny treatment and to misinterpret the requirements of employers and state laws. Be prepared to hold your health plan accountable and expect to challenge them. In THE MEANTIME, NEVER DELAY TREATMENT WHILE YOU FIGHT THE INSURER!

What if I have no health insurance coverage for addiction treatment?

  • First, read your employee benefit handbook carefully. Some employers provide the coverage without the prompting of state requirements. These employers understand the importance of access to addiction treatment for employees and families to ensure safe and productive workforces.
  • Second, all states have designated a lead agency to plan and administer drug and alcohol abuse prevention and addiction treatment services. This lead agency has some limited funding to provide addiction treatment services for people with no insurance or inadequate insurance coverage. (See www.natlalliance.org for assistance in locating resources in your state.)
  • Medicare and state Medicaid plans provide some limited treatment services for those who are eligible.
  • Finally, most addiction treatment programs do provide some free services. However, public dollars and donated services must be reserved for people with no insurance and no other options.
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