Does insurance cover rehab in Texas?

What plans have to cover

Marketplace plans must treat substance use care as an essential health benefit. They cannot turn you down or charge you more because of a past or current substance use disorder, and they cannot set yearly or lifetime dollar limits on these benefits. Exact benefits still differ from plan to plan.

A federal law called the Mental Health Parity and Addiction Equity Act also applies to many job-based plans. In plain words, a plan that covers substance use care should not limit it more strictly than it limits medical and surgical care. That includes copays, limits on days or visits, and approval rules. It does not cover every plan, so ask your employer’s benefits office.

Some products sold as health coverage work differently. Short-term plans and health care sharing ministries may not follow these rules, so read the plan papers closely.

A program can often check your benefits for you, which is a help. Ask it to tell you what it found, then confirm with your plan. If you hear two answers, go by what your plan puts in writing. That check is free, and it does not commit you to the program.

Words you will hear

In network means the program has a deal with your plan. You usually pay less. Out of network means it does not, and you may pay much more or all of it.

Deductible is what you pay before your plan starts paying. Copay is a set amount for a visit or a day. Coinsurance is your share as a percent. Out-of-pocket maximum is the most you pay in a plan year for covered, in-network care.

Prior approval, also called prior authorization, means your plan must agree before care starts. Medical necessity means the plan agrees you need that level of care. Plans often review this during a stay, so ask how many days are approved at a time.

If your plan says no

Ask for the reason in writing. You generally have the right to an internal appeal, where the plan reviews its own decision, and then an outside review by an independent party. Urgent cases must move faster. The program’s staff may be able to send records that support your appeal.

For a job-based plan, the Department of Labor has benefits advisors at 1-866-444-3272.