Insurance & Payment Information
Paying for treatment can feel confusing. This page explains common terms, how to verify benefits, and ways to plan for costs. We don’t diagnose, treat, or make guarantees. Coverage varies by plan, provider, and location. Final eligibility and costs are confirmed by the program and your insurer.
Quick Start:
Verify Your Benefits
Have these ready before you call the program or your insurance company:
- Insurance card (front/back)
- Full name, date of birth, and address
- Policy holder’s name and date of birth (if different)
- Suspected level of care (detox, inpatient, PHP, IOP, outpatient)
- Any safety concerns or recent hospital visits
Ask the program to check your benefits. Also call the number on your insurance card to confirm. Write down who you spoke with, the date, and a reference number.
Key Terms in Plain Language
- Deductible: What you pay each year before your plan starts paying.
- Copay: A flat fee per visit (e.g., $25).
- Coinsurance: A percentage you pay after meeting the deductible (e.g., 20%).
- Out-of-pocket max: The most you’ll pay in a year for covered services. After that, the plan pays 100% for covered care.
- In-network: A provider that has a contract with your plan (usually lower cost).
- Out-of-network: No contract (usually higher cost unless approved).
- Prior authorization (pre-auth): Insurance review required before certain services.
- Medical necessity: Your plan’s rules for when treatment is considered necessary (often based on safety and symptoms).
- EOB (Explanation of Benefits): A statement from your insurer showing what was billed and what you may owe.
Common Ways Treatment Is Paid For
In-Network Insurance
The program has a contract with your plan. You still may owe a deductible, copay, or coinsurance.
Out-of-Network Insurance
Costs are usually higher. Ask about pre-auth, possible exceptions, or single-case agreements (not guaranteed).
Self-Pay / Cash Pay
You pay directly. Some programs offer payment plans or discounts. Get any agreement in writing.
Mix & Match
People sometimes combine insurance for part of care with self-pay services (e.g., additional therapy). Confirm what’s covered first.
What Affects Cost
Level of care:
Detox and inpatient cost more than IOP or outpatient.
Length of stay/hours per week:
More time = higher cost.
Network status:
In-network usually costs less.
Extras:
Labs, medications, and specialty services may be billed separately.
Step-by-Step:
Verifying Benefits (Checklist)
Call the program: ask them to verify your benefits and network status.
Call your insurer: confirm what the program says and ask for a reference number.
Ask about prior authorization requirements and who submits it.
Ask for your deductible, copay/coinsurance, and out-of-pocket max.
Confirm if telehealth is covered and at what rate.
Request a good-faith estimate from the program (self-pay or out-of-network).
Ask how billing works for labs, medications, and physician visits.
Write everything down: names, dates, details.
Questions to Ask Any Program
- Are you in-network with my plan (name of insurer)?
- Do I need prior authorization? Who handles it?
- What is the estimated daily/weekly cost for this level of care?
- How many hours per week and how many weeks do people typically attend?
- What extra charges should I expect (labs, meds, assessments)?
- Do you offer payment plans or financial assistance?
- What happens if insurance denies days/hours—how will I be notified?
What Affects Cost
Ask about self-pay rates and payment plans.
Check community clinics, nonprofits, or public programs in your area.
Ask your primary care provider about referrals and low-cost options.
Some employers and schools offer counseling benefits or assistance programs.
Appeals & Denials (Overview)
If coverage is denied or reduced:
- Ask for the reason in writing and the criteria used.
- Request that the program send clinical notes for a review (with your consent).
- File an appeal by the deadline listed on your denial letter.
- Keep records of every call and letter.
(Programs often help with this process, but outcomes are not guaranteed.)
Medication Costs (When Appropriate)
For some alcohol and opioid use disorders, FDA-approved medications may be covered. Ask:
- Is the medication on the formulary (covered list)?
- Do I need prior authorization?
- What will the pharmacy copay be?
- Are there generic or assistance options?
Telehealth Coverage
Many plans cover virtual therapy and medication visits similarly to in-person care. Ask if coverage differs by state, provider type, or platform. Confirm rules for labs and drug screens if required.
For Loved Ones: How You Can Help
- Offer to collect insurance info and make the first benefits call together.
- Help track names, dates, and reference numbers in one place.
- Ask about family sessions and what’s covered (with consent).
- Keep boundaries clear around money; consider paying vendors directly (e.g., pharmacy) instead of giving cash.
Sample Call Script
(Use Your Own Words)
Hi, I’m calling to verify behavioral health benefits for [Member Name, DOB]. The provider is [Program Name], NPI [if known]. We’re asking about [detox / inpatient / PHP / IOP / outpatient / telehealth]. Is the provider in-network? Do we need prior authorization? What are the deductible, copay/coinsurance, and out-of-pocket maximum? Please give me a reference number for this call.
Simple Budget Planner (At-a-Glance)
- Deductible remaining this year: ________
- Copay per visit or coinsurance %: ________
- Estimated visits/hours per week: ________
- Transportation/childcare costs: ________
- Medication/pharmacy estimate: ________
- Total monthly estimate: ________ (update after EOBs arrive)
Important Reminders
- Benefits quotes are estimates, not guarantees.
- Coverage can change month to month or when the plan year resets.
- Keep every EOB and compare to your bills; call if something looks off.
- If safety is urgent, seek care first—payment questions can follow.
Featured Facilities
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Helpful Resources
In Crisis? Get Immediate Help.
If you or someone you know is in immediate danger or experiencing a medical emergency, call 911. You can also contact the Suicide & Crisis Lifeline for free, confidential support 24/7 at 988.
Additional Resources (Optional but Helpful):
- SAMHSA’s National Helpline: 1-800-662-HELP (4357)
- National Domestic Violence Hotline: 1-800-799-SAFE (7233)
- Crisis Text Line: Text HELLO to 741741