Health Plan of Nevada and Drug Treatment
The Health Plan of Nevada is Nevada’s most experienced and oldest health insurance provider. The company has provided health insurance since 1982 and was acquired by the UnitedHealth group in 2008. Health Plan of Nevada’s network of providers consists of well over 2,000 physicians and healthcare professionals as well as coverage at over 200 different facilities and hospitals.
Health Plan of Nevada offers a variety of plans, including:
- Point of service plans
- Vision, dental, and life plans
Health Plan of Nevada offers numerous benefits that are covered with a three-tier plan.
Tier III (Non-Plan Provider Benefit Option): Benefits at this tier are in effect when the individual obtains covered services from a non-plan provider. At this tier, the individual is responsible for paying all costs at the time of service, and claims forms must be submitted for all non-plan providers.
Tier II (Expanded Plan Provider Benefit Option Non-Plan Provider Benefit Option): Benefits provided in this tier occur when the individual obtains services that are covered from a provider who is an independent contractor and allowed to provide services to members enrolled in Point of Service plans. The out-of-pocket expenses for these services are higher than the services that are covered under Tier I.
Tier I: Benefits at this tier occur when the individual gets covered services through a Health Plan of Nevada primary care provider. Out-of-pocket expenses are far lower than at the other two tiers.
According to information provided by the Health Plan of Nevada, certain procedures, treatments, and diagnostic tests may require special orders or preauthorization.
Does Health Plan of Nevada Cover Detox and Rehab Programs?
Yes, all insurance plans must cover some of the cost of substance use disorder treatment. First of all, the 2010 Patient Protection and Affordable Care Act (Obamacare) passed in 2010 provided that most insurance providers must provide for essential health benefits in their services. These services include laboratory services, vision care, emergency services, mental health treatment, and treatment for substance use disorders. Both private and group insurers must provide these services. The types of services that are provided for substance use disorder treatment may vary depending on the individual plan that one is enrolled under.
Second, according to the Health Plan of Nevada website, considerations include:
Inpatient or residential treatment: These types of programs for substance use disorders are covered at least in part, but depending on the individual’s plan, certain expenses may not be covered. Individuals may have to pay out-of-pocket costs for certain services.
Outpatient substance use disorder treatment: These services are typically covered at least in part, depending on the individual’s plan and the provider.
Therapy services: These services are typically covered to some extent.
According to its website, Health Plan of Nevada does offer coverage for rehabilitation and detoxification from alcohol or other substances. There are also special requirements when it comes to being qualified to enter one of these programs, and pre-certification is required. Copays exist for many of the above services, depending on the rate, provider, and the medical necessity of the treatment. According to the website, individuals should check with their policy or their insurance representative regarding out-of-pocket costs.
What Determines Coverage for Substance Use Disorder Treatment?
According to the American Society for Addiction Medicine (ASAM), the majority of insurance companies approve treatment for substance abuse based on the notion of medical necessity. The major facets of medical necessity are outlined below.
- The services in question are required for the diagnosis or treatment of the suspected presence of a condition or for a formally diagnosed condition or illness.
- The treatment services requested are appropriate to be used for the disorder, and they meet the standards of competent medical practice; the services have empirical evidence to support their use for the specific illness or condition.
- The proposed treatment must be required for reasons beyond the convenience of the potential patient.
- Insurance companies also evaluate costs and will approve or disapprove of a particular mode of treatment if it is likely to be less costly and produce equivalent and/or superior results as other available forms of treatment.
Based on the information provided by ASAM and Health Plan of Nevada, the types of criteria that most likely need to be satisfied in order for treatment to be covered are outlined below.
- Withdrawal symptoms can be managed in an adequate manner at the level of care requested.
- The patient is cognitively appropriate and able to fully participate in the requested treatment.
- The patient has no other medical problems that would hinder their ability to participate in the treatment.
- The patient is motivated to participate in the treatment.
- There is a significant risk that the individual will engage in self-harm or present a serious threat to others if they do not get the treatment.
- The individual’s abuse of substances is obviously resulting in significant issues in at least two areas of their functioning.
- There is significant evidence that treatment at a lower level would not sufficiently satisfy the individual’s treatment needs.
- There is sufficient evidence that unless the person gets the requested treatment, their condition will continue to worsen.
- There is significant evidence that the person’s current living arrangements may endanger their recovery.
Often, the referral source can dictate how seriously insurance companies view the need for a specific mode of treatment for a substance use disorder. Insurance companies often rely more on referrals written by physicians, particularly psychiatrists and addiction medicine physicians, when considering the need for substance use disorder treatment compared to referrals written by therapists or counselors. Referrals that provide evidence that the individual meets the formal diagnostic criteria for the particular substance use disorder in question as specified by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition is also often required.