Insurance & Costs
Insurance can feel like the hardest part of getting help. A little knowledge goes a long way toward avoiding surprise bills and unnecessary denials.
The basics
In-network providers have contracted rates with your plan, which usually means lower costs. Out-of-network care may be partly covered, or not at all — always ask before admission.
Many plans require approval before certain levels of care begin. The provider usually submits it, but it helps to confirm it was approved — and for how many days.
Your deductible is what you pay before coverage kicks in; your out-of-pocket maximum caps what you pay in a plan year. Ask where you stand on both.
Under the federal parity law (MHPAEA), most plans must cover mental health and substance use care no more restrictively than comparable medical care.
Insurers approve care they consider medically necessary. Clinical assessments and documentation from providers are what support that decision.
If care is denied, you have the right to ask why in writing and to appeal — internally first, and often through an external review.
Call your insurer
Have your member ID ready, write down the date, the representative’s name, and a call reference number for every conversation.
Your checklist
✓ What are my behavioral health benefits for substance use treatment?
✓ Is this specific program in-network?
✓ Which levels of care require prior authorization?
✓ What are my deductible, copays, and coinsurance?
✓ How much of my deductible and out-of-pocket maximum is met?
✓ Is there a limit on the number of days or visits?
✓ How do I file an appeal if care is denied?
If you’re denied
1. Ask for the denial reason in writing, including the criteria used.
2. Ask the treating provider to support an appeal with clinical documentation.
3. File the internal appeal before the deadline — an expedited review may be available when care is urgent.
4. If the denial is upheld, you can often request an independent external review.
Take the next step
Our guides go deeper on authorization, appeals, and understanding your benefits.
