Will my insurance cover mental health? What about chemical health and treatment? A guide to understanding how to use your benefits for the best mental health and chemical dependency treatment available to you.

Before I go into more detail, I want to share that understanding insurance benefits can be highly nuanced and complicated, and I am not an expert. I help people navigate their benefits daily for treatment of various kinds and here is what I have learned over the years. Please comment or DM me if I get any details wrong or you have anything to add.

Why is this important?

The reason I am writing this article is due to the general misunderstanding of insurance benefits, and what they cover with the clients and families I work with in my practice. I have even found that most mental health providers do not have anything resembling a firm understanding of insurance benefits and their implications. We providers often find wrapping our heads around insurance benefits to be convoluted, boring and aggravating. Yet, benefits and payer systems are so important to understand because they can be the difference in finding quality treatment, financial stability or even life and death.

When trying to figure out what their insurance covers, many of the individuals and families I work with either end up calling their insurance company or trusting the initial provider they see such as myself hoping they are getting accurate information. If the insurance company has an up to date list of in-network providers or the mental health professional has a good understanding of benefits this may not be a bad way to start. However, this is not always the case. Often, when you  you call your insurance company, the information they give you is inaccurate. Sometimes different treatments that are in-network are not listed or improperly listed as not covered. Similarly, the first provider you see who is referring you to a specific treatment also may be just as ignorant to what your benefits afford you and just refer you to where they send everyone else. It pays to do your homework, but when you are in a crisis, or don’t even know where to begin navigating the system where do you turn? The below guide will give you a good starting point to understanding the options you have available so you can ask the right questions to your insurance provider or treatment professional.

Background

In 2012, I had my first counseling internship at St. Joseph’s Hospital in St Paul, Minnesota, within their outpatient treatment for mental health and substance use disorders. I had worked with clients in the past, but this was the first time I would be able to officially work with them as a counselor. Almost all counselors get into the field of Mental Health and Chemical Dependency (MICD), to work directly with people. Bright-eyed and bushy-tailed counselors to be are informed by our professors that there is more paperwork and navigating bureaucracy in this field than talking and helping. The reason I bring up this internship is that for the first time I realized I needed to understand insurance and payer systems to be a better clinician. If  clients are not able to access services what good is my counseling ability? Will my insurance cover mental health and chemical health? Liz, my patient and wise supervisor, sat me down and drew a quick chart that really simplified the different types of payers. Though my brain nearly exploded, I wondered why I had not learned this sooner! I will try to do the same for you, but first here’s some more background.

Why understanding your benefits is not straightforward

There was a time when Mental Health or Chemical Health services were not covered by insurance as they were not looked at as the same as a medical ailment. When that changed, and the behavioral health industry started being able to bill the same way as in medical, payers were then responsible for covering mental health and only sometimes chemical health disorders; this could be expensive. Even after it was required to have mental health be covered on all plans, individuals can still opt out of chemical health coverage so always double check to be sure this isn’t the case on your plan! Insurance companies and other payer systems such as Medicare need to be sure the treatments are justified. This is why I have to provide a diagnosis to clients wanting to use insurance, even after one visit!

It is easy to villainize the insurance companies or government payers for all the hoops that need to be jumped through. And believe me they provide enough unnecessary roadblocks to care that does their reputation no favors. On the other hand, in our current system, if everyone got any expensive treatment they sought justified or not, healthcare costs would go up for everyone. Sadly, at this point in our society we are far more on the side of individuals not getting enough access to care. For most insurance plans there is profit motive and covering expensive services does not help with the bottom line. Therefore, finding out how to access your mental health or chemical dependency benefits can often be like trying to find out how to make a return of something you bought from a shopping site. They don’t make it obvious or easy because they would prefer you didn’t. To be fair I have had a lot of help from customer service reps at different insurers but the standard for navigating your benefits is far from straightforward.

Below is a guide to help you understand what kind of plan you have and what the advantages and disadvantages of those types of plans can be.

The Insurance Plan Guide

Commercial plans and Subsidized Plans.

Employer-Based Plans: Simply, these are insurance plans you get through an employer. This is the most common form of coverage. In Minnesota, roughly 55% of individuals are covered by an employer sponsored plan from theirs, their spouses or a parent’s job.

Marketplace Plans: With the advent of The Affordable Care act, the government subsidizes insurance plans individuals can buy on the marketplace. These are similar to commercial plans but the government acts in the same way the employer does. The individual pays a premium and the rest is subsidized by the government. Prior, if you did not have an employer, or had a pre-existing condition you were out of luck if you wanted any type of plan that was near affordable. These plans can often be great for many, but similar to commercial plans they vary greatly plan to plan and can have many downsides, therefore I am lumping them together for all intents and purposes with commercial plans. In Minnesota 8% of residents are insured under marketplace plans.

Pros:

1. Much of the cost of premium is covered by your employer: There is generally an employee contribution to the cost of the plan, but much is subsidized by your employer.
2. Depending on the plan, you may have a lot of options to cover mental health and chemical dependency provider: For this type of insurance the access to different providers is the biggest pro as a well as con because commercial plans vary so much from one to the next. Understanding what is offered by a plan is so specific and complicated it can be maddening. However, if someone does have a commercial plan the first thing I do is run the benefits to see what the quality of these benefits are for mental health and chemical health.
3. Potential Access to out-of-state providers: Think of those who come to Minnesota to the Hazelden for treatment or sick patients traveling to the Mayo clinic for the best surgery specialist they can find. Many of those individuals are wealthy and pay out of pocket but your plan may be in-network and cover certain providers in other states. This even goes for some higher end residential MICD treatments (think Betty Ford or Promises Malibu) across the country. Good treatment does not have to be on a beach in California by any means but there are some quality treatments that are in beautiful locations that do provide amazing care. I find so many times clients are unaware that they have access to top quality care in other states because no one really told them.
4. Depending on the plan, there may be lower costs for high quality treatment: Again, this varies greatly between plans, but sometimes you may have a great plan with extensive MICD coverage. I have seen people shocked to learn that a quality MICD residential treatment in another state that would have cost upwards of 50k or more to be fully covered.

Cons:

1. Deductibles, copays, co-insurance and out-of-pocket (OOP) Max: These gut wrenching phrases are the fine print of insurance plans that ensure the house always wins. If you have extremely high deductibles, copays, co-insurance or OOP max, sometimes it’s like not having insurance at all. You end up paying that full yearly deductible if you or a loved one needs residential treatment for MICD then before you know it the year is up and they all reset. Your insurer may have paid almost nothing and yet you still paid the premiums. Even if the insurer did provide a lot of coverage, with the high deductible you still inquer financial burden in your time of need. Protecting yourself at these vulnerable and unfortunate times is the whole point of insurance in the first place! Yet, you can still end up in serious financial hardship. Often families have to make some really tough choices pinning finances vs. health.
2. Paying premiums: It seems par for the course, but with commercial plans it is likely you have to pay for some or all of the premium. That is money out of your pocket each month. With countries with universal or socialized care, this cost is already built in to their tax system and citizens do not worry about this. When we talk about the government provided plans below you will further see how this is a negative.
3. Specific providers may be out-of-network with your plan: More and more insurance providers are doing away with out-of-network benefits or making them so expensive that few would choose to use them. This means each provider needs to be credentialed with each insurer and negotiate rates. There are so many different plans that each must be run by the provider to see if you are eligible for coverage. I find that more commercial plans are out of network with certain providers than many of the government run or fully government subsidized plans (not the partially subsidized marketplace plans.). A lot of criticism of the newer marketplace plans is that they have more expensive premiums, and higher deductibles/OOP Max with less options of providers you can see. In 2015 I had a marketplace plan that really worked well for me but was shocked that in 2016 the options were way more expensive and inadequate. I had less options of providers and had to pick a single health system, such as North Memorial to see all my providers when I already had established providers in other networks. This really exemplifies the problems with commercial insurance plans.
4. They may deny you coverage: Unfortunately insurance companies are business that seek to make profits like any other. This sets up a situation where there is an incentive for them to deny you services. This is one of the main arguments for government run universal healthcare. Sadly, this means that you may have to fight to get the coverage you need or you may not be able to complete treatment once you do get approved. Many people have died due to being denied mental health and chemical dependency coverage. This is not just a phenomenon in the medical world.

Government Provided Plans

Medicaid or Medical Assistance/MinnesotaCare and PMAP Plans: These plans are for lower income residents who are not eligible commercial plans or cannot afford marketplace plans. About 15% of Minnesota residents are on government provided plans for low income individuals. In order to qualify for these plans, you need to be a Minnesota resident and meet a certain income threshold. For example, as a single adult you need to make less than about 17k per year. There are other variables and sometimes individuals can still apply if they have other insurance. Here is a chart of eligibility. Medical Assistance Eligibility.

We also have PMAP plans, (Prepaid Medical Assistance Program) which are medicaid plans managed by major insurers such as Blue Cross or UCare. As of recent, when someone is placed on MinnesotaCare they are shortly after transferred to a PMAP managed by the private insurer. The consumer gets to have a choice in which PMAP they choose although options are limited based on which companies choose to opt into the program. i.e. the ones who find it to be financially worthwhile. It is often confusing for clients and providers to tell the difference between a PMAP and Commercial plan for example Blue Cross. If the plan was provided from an employer it is commercial and if it was provided by the state, it is a PMAP. They will often be labeled differently i.e. Blue Plus.

Medicare: Medicare is a government provided plan for seniors and those with disabilities. We are hearing a lot about medicare lately due to the debate about giving citizens access to medicare i.e. universal coverage. There are certainly advantages to being on medicare but there are some serious disadvantages when trying to access mental health and chemical health services.

Pros:

1. They generally cost nothing out of pocket!: There are no deductibles, co-insurance, copays, OOP Max. Nothing! If you qualify for MinnesotaCare you are not responsible for out of pocket costs costs. However, this is different with Medicare, where there may be some out of pocket costs and the need for many to purchase supplemental plans. To be honest, this is not my area of expertise, but reference here for out of pocket costs. Medicare Costs.
2. They are covered by most all healthcare providers in Minnesota: In Minnesota we have one of the most, if not the most generous medicaid programs in the country with MinnesotaCare. I had a client move from Florida to Minnesota for treatment. I got him onto Minnesota Care and he was shocked at how good the benefits were. He came into my office and told me, “I went to see the doctor, and it wasn’t in some crowded clinic that only sees people on medicaid. I didn’t have to wait for hours and the doctor was actually a legitimate good doctor!” Sadly the quality of care and accessibility to care for those on medicaid are generally not nearly the same quality as here in Minnesota.
3. It easy to sign up for, and you do not have to be a resident long to get on a plan: Sometimes for my out of state clients, I will recommend them to come to Minnesota for treatment because of our benefits system so they can continue to get adequate coverage for as long as they are here. This is another reason why Minnesota is attractive for the immigrant population. Certainly not the weather.
4. They are often good about approving services: I have rarely heard of someone being denied treatment by either Medical Assistance or a PMAP plan. If a provider makes a clinical recommendation and properly documents the rationale they rarely in my experience push back. Maybe a provider reading this has had a different experience but few of my clients have been denied necessary care.

Cons

1. Be poor with great healthcare or be comfortable with no healthcare?: This is often a decision individuals have to make when they are hovering around the income threshold of medical assistance. If I am making one dollar under the about $17,000 eligibility threshold I can have this amazing free healthcare program but if I am making $17,001 I have nothing and have to purchase a marketplace plan that is way more expensive and get worse coverage. It’s an easy decision, but what if the job you want will pay 30k or even 40k for that matter? You then start to play a game no one should have to play, and this can incentivise individuals to not work instead of get ahead financially because it would mean giving up their healthcare.
2. Many providers will not take Government Provided Plans:  Though the coverage can be quite generous for variety of providers there are some providers that will not be covered  by a state provided plan. If a client has state insurance they will not be eligible for out of state programs. So no luxury beach treatment or even some of the local higher end local treatments like Hazelden or Beauterre. Not as much for Medical Assistance, but Medicare is very strict about who can provide services. This is one of the things that freaks me out a bit when I hear about medicare for all, though this exclusivity would likely have to change. For example, all Medicare services have to be hospital based. Most of the top treatment centers are not hospital based and aren’t necessarily any cheaper. Therefore, once a senior someone is on Medicare, their treatment options are very limited. This is really sad because they are often denied a quality of care that are afforded to other non-seniors. Another example is that only Social Workers and Psychologists can provide services to seniors and those on disability. As a social worker, that is okay for me but many of my qualified colleagues that are Licensed Counselors, or Marriage and Family therapists cannot see medicare clients. With all these limitations, seniors and those with disabilities are often not given adequate access to the same care others get have to wait much longer and have to go further to get care.

Conclusion

Hopefully, this article shed some light on your benefits for mental health and chemical health services. The point of this article is so that you know the right questions to ask when making big decisions as to what type of treatments should I look into or what type of insurance plan should I get. If you have a family member who has a history of mental health or substance use disorders, always make sure you understand what types of treatments you are covered for and what your out-of-pocket costs would be. As bad of a reputation insurance companies get, having a good plan can save your life financially and literally, so it is important to make informed choices. Equally, having a provider  who understands benefits is essential to get access to the right care. Feel free to shoot me a message or give me a call if you or a family member is needing help accessing care.

First of all, there really isn’t such a thing as a functional addict. Individuals who have moderate or severe substance use disorders (addictions) have severe dysfunctions; it is part of the definition. It makes more sense to identify individuals with substance use disorders that are relatively high-functioning as opposed to using the fallacious term functional addict. A number of individuals with moderate to severe substance use disorders do appear to be able to control certain aspects of their lives while at the same time hiding dysfunctional behavior.

Many high-functioning addicts are working, have good incomes, are college-educated, and are often partnered or married. They use their drug of choice at rates that would qualify them as having substance use disorders but are able to conceal many of the complications associated with their substance abuse.

These individuals are relatively successful at restricting their substance use and abuse to specific times or situations as opposed to appearing as if they are driven to use substances. Their ability to restrict their use leads to the illusion that the person controls their substance use or abuse; however, this is not the case. Simply restricting use to specific times is not a disqualifying feature of having a substance use disorder and in fact is in line with the diagnostic criteria set forth by APA.

Despite being so-called functional or high-functioning addicts, these individuals still fail to maintain a number of responsibilities or personal commitments due to their substance abuse. However, they are able to minimize their failures to maintain certain personal commitments while maximizing the fact that their drug abuse helps them remain functional and cope with the pressures of life. The situation is often the ultimate hypocrisy.

High-functioning addicts will often engage friends or family members to cover up for them when they do experience issues with their substance abuse. For instance, an individual recovering from a long night of drug abuse may ask a spouse to call into work for them and say they are sick, or may hold off paying certain bills or do without certain accommodations as a result of financial issues associated with their substance use. The majority of relatively high-functioning addicts typically suffer from some other psychological disorder, such as anxiety and depression, and they have convinced friends and family that these issues are just the “normal” state of affairs for them.

What is drug addiction?

Is addiction a disease or simply a lack of willpower? Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is a disease, and is also considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs.

Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of an organ in the body, both have serious harmful effects, and both are, in many cases, preventable and treatable. If left untreated, they can last a lifetime and may lead to death.

Why do people take drugs?

In general, people take drugs for a few reasons:

• To feel good. Drugs can produce intense feelings of pleasure. This initial euphoria is followed by other effects, which differ with the type of drug used. For example, with stimulants such as cocaine, the high is followed by feelings of power, self-confidence, and increased energy. In contrast, the euphoria caused by opioids such as heroin is followed by feelings of relaxation and satisfaction.
• To feel better. Some people who suffer from social anxiety, stress, and depression start using drugs to try to feel less anxious. Stress can play a major role in starting and continuing drug use as well as relapse (return to drug use) in patients recovering from addiction.
• To do better. Some people feel pressure to improve their focus in school or at work or their abilities in sports. This can play a role in trying or continuing to use drugs, such as prescription stimulants or cocaine.
• Curiosity and social pressure. In this respect, teens are particularly at risk because peer pressure can be very strong. Teens are more likely than adults to act in risky or daring ways to impress their friends and show their independence from parents and social rules.

If taking drugs makes people feel good or better, what’s the problem?

When they first use a drug, people may perceive what seem to be positive effects. They also may believe they can control their use. But drugs can quickly take over a person’s life. Over time, if drug use continues, other pleasurable activities become less pleasurable, and the person has to take the drug just to feel “normal.” They have a hard time controlling their need to take drugs even though it causes many problems for themselves and their loved ones. Some people may start to feel the need to take more of a drug or take it more often, even in the early stages of their drug use. These are the telltale signs of an addiction.

Even relatively moderate drug use poses dangers. Consider how a social drinker can become intoxicated, get behind the wheel of a car, and quickly turn a pleasurable activity into a tragedy that affects many lives. Occasional drug use, such as misusing an opioid to get high, can have similarly disastrous effects, including overdose, and dangerously impaired driving.

Do people freely choose to keep using drugs?

The initial decision to take drugs is typically voluntary. But with continued use, a person’s ability to exert self-control can become seriously impaired; this impairment in self-control is the hallmark of addiction.

Brain imaging studies of people with addiction show physical changes in areas of the brain that are critical to judgment, decision-making, learning and memory, and behavior control. These changes help explain the compulsive nature of addiction.

Why do some people become addicted to drugs, while others do not?

As with other diseases and disorders, the likelihood of developing an addiction differs from person to person, and no single factor determines whether a person will become addicted to drugs. In general, the more risk factors a person has, the greater the chance that taking drugs will lead to drug use and addiction. Protective factors, on the other hand, reduce a person’s risk. Risk and protective factors may be either environmental or biological.

What biological factors increase risk of addiction?

Biological factors that can affect a person’s risk of addiction include their genes, stage of development, and even gender or ethnicity. Scientists estimate that genes, including the effects environmental factors have on a person’s gene expression, called epigenetics, account for between 40 and 60 percent of a person’s risk of addiction. Also, teens and people with mental disorders are at greater risk of drug use and addiction than others.

What environmental factors increase the risk of addiction?

Environmental factors are those related to the family, school, and neighborhood. Factors that can increase a person’s risk include the following:

• Home and Family. The home environment, especially during childhood, is a very important factor. Parents or older family members who use drugs or misuse alcohol, or who break the law, can increase children’s risk of future drug problems.
• Peer and School. Friends and other peers can have an increasingly strong influence during the teen years. Teens who use drugs can sway even those without risk factors to try drugs for the first time. Struggling in school or having poor social skills can put a child at further risk for using or becoming addicted to drugs.

What other factors increase the risk of addiction?

• Early Use. Although taking drugs at any age can lead to addiction, research shows that the earlier a person begins to use drugs, the more likely he or she is to develop serious problems.³¹ This may be due to the harmful effect that drugs can have on the developing brain.³² It also may result from a mix of early social and biological risk factors, including lack of a stable home or family, exposure to physical or sexual abuse, genes, or mental illness. Still, the fact remains that early use is a strong indicator of problems ahead, including addiction.
• How the drug is taken. Smoking a drug or injecting it into a vein increases its addictive potential. Both smoked and injected drugs enter the brain within seconds, producing a powerful rush of pleasure. However, this intense high can fade within a few minutes. Scientists believe this starkly felt contrast drives some people to repeated drug taking in an attempt to recapture the fleeting pleasurable state.

The brain continues to develop into adulthood and undergoes dramatic changes during adolescence.

One of the brain areas still maturing during adolescence is the prefrontal cortex—the part of the brain that allows people to assess situations, make sound decisions, and keep emotions and desires under control. The fact that this critical part of a teen’s brain is still a work in progress puts them at increased risk for making poor decisions, such as trying drugs or continuing to take them. Introducing drugs during this period of development may cause brain changes that have profound and long-lasting consequences.

*National Institute of Drug Abuse

What Is Mental Health?

Addiction and Co-Occurring Disorders