Finding Treatment 101: How to Select a Program
By Holland Counce, Director of Admissions
*This should only be used for educational purposes. Every healthcare provider, insurance plan, and state have different regulations, requirements, and policies that determine how care is delivered and covered. This is only meant to provide some basic information in the hopes of helping families and individuals.
—- The process of finding the right treatment program for you or your loved one can be a stressful and complicated experience. Addiction can feel hopeless and often be a crisis for the individual and their family. Finding treatment should not be a barrier to building a beautiful, meaningful life in recovery. As the Director of Admissions for Longbranch Healthcare, I spend a lot of time on the phone with families who are in crisis. Their loved one is very sick and needing help, but they are struggling to navigate the confusing landscape of substance use disorder (SUD) treatment. When you or your loved one is ready and willing to get help, it’s important to know what your options are and how to take the next steps towards wellness. Understanding the different levels of care, insurance coverage, and philosophies of treatment is not easy. My hope is that anyone who reads this post feels slightly more informed about how to find the best treatment for themselves or a loved one.
Levels of Care
Within SUD treatment, there exists many different levels of care that provide various services to individuals who are struggling with addiction. If you have insurance with mental health and substance abuse benefits, you might be able to get coverage for detox/inpatient, residential, partial hospitalization programs (PHP), intensive outpatient programs (IOP), and outpatient levels of care. A treatment facility must be licensed to offer the different levels of care with city, state, federal, and accreditation agency regulations depending on the location and type of care being provided.
—- Detox, inpatient and residential treatment are when the individual with a SUD resides within a facility while receiving medical and clinical care. These programs can vary in length from a few days to many months. Certain facilities may only offer short-term medical detox, or it may be a part of a more comprehensive program. This is the most intensive level of care to treat addiction and mental health issues. In residential treatment, it is easier for the healthcare provider to offer more in-depth services than otherwise possible. For example, we are able to do things like equine therapy, yoga and exercise, trauma-informed therapies, and daily medical monitoring with medication management at our residential facility. This would be hard to do at an outpatient level of care. How long someone stays at a detox or residential level of care depends on several factors like insurance authorizations, clinical recommendation, or philosophy of treatment.
—- Partial Hospitalization Programs (sometimes known as day programs) offer comprehensive clinical services but do not provide housing or living accommodations; however, some facilities do provide housing as a service while in their PHP program. They may charge a room and board fee. Clients will go to the facility for different therapeutic groups and activities and may still also receive physician-managed care. This level of care is less intensive than inpatient/residential but more intensive than IOP. Healthcare providers who offer the PHP level of care follow certain guidelines and restrictions set forth by city, state, insurance company, or accrediting agency regulations like any other level of care listed in this blog post (ugh, I promised myself I’d never say “blog post”).
—- Intensive Outpatient Programs meet for several hours on certain days of the week for group therapy and may include some individual counseling and physician-assisted care. IOP is great because it allows individuals to work and live at home while getting effective treatment, but it requires that they be medically and clinically appropriate to treat in a program that doesn’t have nurses, doctors, and counselors on-call 24/7. If someone will experience uncomfortable or dangerous withdrawal symptoms from their substance abuse, they will likely need to start at a higher level of care before beginning an IOP. While many IOPs may have similar structures and schedules, they all vary greatly in their treatment approaches and what services are offered.
—- Finally, Outpatient care is individual services like seeing a counselor weekly, an evaluation, assessment, or attending a group 1-2x a week. This is the least intensive level of care. Often, an individual will start at a higher level of care and transition through the levels of care ultimately ending with outpatient. Or, people who are not quite ready to address their SUD may start at this level of care as they work through barriers and ambivalence towards more structured care. This level of care is generally thought of as part of an important aftercare service for the maintenance and continuation of the intensive work done at higher levels of care.
—- The severity of the SUD and assessment is what often determines which level of care is appropriate. There are also other levels of care that exist, but most insurance companies don’t have benefits that can help with coverage. These are generally extended care programs or sober living-type services that can be part of a good aftercare plan. Often, transitioning through the different levels of care starting with the most intensive is a good way to build a strong foundation in recovery. The continuum of care is important to consider when choosing a facility and level of care for you or your loved one.
This is where things can get tricky for families and individuals. Insurance is wonderful because it can assist with (or even fully cover) expensive treatment in many circumstances. EVERY insurance plan is vastly different (even within the same company!) and it’s important that you know how YOUR plan is structured! If your plan has substance abuse and mental health benefits, you want to know whether it has benefits for all the levels of care that we just talked about. Next, you’re going to want to know what your in-network deductible, out-of-pocket maximum, and coinsurance rate is to help understand what the out of pocket expense to you might be. Also, it’s good to know if you have out-of-network benefits and what those are (we’ll talk about those later). So, GENERALLY speaking, you will need to come up with your deductible. You might also have copayments or coinsurances that will have to be collected. Many treatment programs offer payment plans if you have a high deductible.
—- What are in-network benefits? An in-network treatment program has a contract with your insurance company for your specific plan to be a part of their preferred network of providers. In-network benefits often have lower deductibles and out of pocket maximums than out-of-network benefits. Now, out-of-network benefits. What are they? Well, just because a treatment facility doesn’t have a contract with your insurance company for your specific plan doesn’t mean you can’t get services from them. For the most part, out-of-network deductibles and out-of-pocket maximums are higher than in-network ones (it’s an incentive for you to go to a preferred provider). It’s like a separate set of benefits. If you obtained medical services that applied towards your in-network deductible, it probably did not go towards your out-of-network deductible. But remember, every plan is DIFFERENT! You can always call the member services number on the back of your insurance card and speak to a representative who can explain your benefits. Some plans DO NOT have out-of-network benefits (know YOUR plan!).
—- Ok, so….. you know a little bit more about your plan…now what? Call an admissions representative with the healthcare provider and they will do a “verification of benefits” which means they will look at your plan to see what type of benefits you have and if you’ve satisfied any of your deductible and out-of-pocket. This is where it can be confusing for individuals and families because every healthcare facility is in-network or out-of-network with different plans. Some places may not accept your insurance at all, others can only use out-of-network benefits, some may or may not accept Medicaid or Medicare, some may not have the level of care (remember those?) that your plan has benefits for. It’s tricky! Don’t lose hope. Call around, talk to different places, and ask the right questions. You can also call your insurance company and they will provide you with a list of in-network providers.
—- Ok, you found a program that you are comfortable with and can use your insurance benefits. Next, the healthcare provider will often need to prove something called “medical necessity” to be able to use those benefits. Essentially, the insurance company wants to know why the level of care they are being asked to authorize treatment days (or sessions, units, visits) is the appropriate level of care. The provider will make their case based on assessments and information obtained from the potential client and then submit an initial authorization. If approved, they will often give you a certain amount of days/units/visits/sessions. When those expire, the insurance provider will then do a utilization review. They want to know why they should continue authorizing more treatment. The healthcare provider will make their case based on the individuals progress and charting. This will go on until the insurance company eventually decides that the level of care the patient is currently receiving treatment at is no longer medically necessary. Then, they are often willing to step the individual down to a less intensive level of care. If you were to start at the highest level of care and get transitioned over time to the lowest, it would go from detox to inpatient/residential, to PHP, to IOP, and then finally outpatient. Have I lost you yet? If you don’t have insurance, meet medical necessity, or have benefits that cover SUD treatment, you generally have self-pay options or can utilize community programs designed to be low or no cost. Some programs may even help you enroll in an insurance plan like Medicaid if you qualify. Hopefully, you understand a little bit more about how insurance and substance use/mental health treatment works. Don’t worry, it’s far more complicated and nuanced than even I can wrap my small brain around, but I think we covered some of the basics (phew).
Philosophies of Treatment
What’s the difference between all these healthcare providers and their services? Great question! Every treatment program has a different approach to SUD/mental health treatment. A treatment program can differ in their philosophy in a variety of ways. It’s important that you ask the program representative how they treat mental health and SUD’s and that you feel comfortable with what you HEAR and SEE. Some treatment may be rooted in evidence-based practices while others may be more experimental or possibly faith-based. Physicians and therapists all approach recovery from different medical and theoretical perspectives. How one facility manages withdrawal symptoms may be vastly different from how another one does for the same person. Some programs take strong stances on certain medications in the treatment of substance use disorders and mental health issues while others may not. The experience and educational levels of the treatment staff can range to a surprising degree as there are many different designations and licenses that can be obtained to offer various services. Is the family an integral part of the individual’s treatment or should the treatment solely focus on the individual battling addiction issues? How personalized should treatment plans be? Is group therapy sufficient or should individual, couples, and family counseling also be integrated into the program? There are thousands of questions and beliefs about how substance use disorder treatment should be delivered. If everyone has a different take on how to treat this health problem, how do you know who to choose? Well, what is important to you? Do you believe the program that you are investigating can treat the underlying issues that cause suffering and remove the barriers that prevent people with SUDs from meeting their goals? Are your values in alignment with theirs? Our philosophy at Longbranch Healthcare is founded in the belief that substance use and co-occurring disorders require comprehensive, holistic, and individualized treatment that addresses the mind, body, spirit, and family of someone who is suffering with addiction. We employ a team of passionate doctors, counselors, psychologists, nurses, registered yoga teachers, recovery advocates, chefs, and administrators who care deeply about the success and wellbeing of our clients. Our approach involves individual counseling, group therapy, family workshops, yoga and meditation, exercise and nutrition, 12-step immersion, comprehensive aftercare planning, trauma-informed modalities, and evidence-based practices. We believe that the environment that you recover in should be conducive to recovery and restoration.
—- The vicious cycle can end. Families can heal. Healthy, happy lives filled with purpose and meaning can be rebuilt in recovery with a little help. You are not alone. Addiction is treatable and recovery is beautiful.