About Private Insurance

Teras Position Statement on Insurance Coverage for Court Mandated Treatment Services


               Teras Intervention and Counseling Inc. is a 501 (c) 3 not for Profit Corporation with a mission to provide quality, affordable and easily accessed treatment for people who are facing a variety of difficult circumstances; receiving a DUII and diversion, court mandated anger management and domestic violence intervention group education and child protective services mandated treatment for custodial reasons.

         We want you to have every available resource to ensure you are successful in whatever you do. For some that will be the Oregon Health Plan which we currently accept. For others you may have the option of using private insurance or paying your own way however  many private health insurance plans will not pay the entire cost of outpatient treatment.

        Our official position at this time is that private insurance may not always be the best resource for alcohol and other drug dependency treatment and we will not encourage individuals to use insurance unless absolutely necessary to ensure the best possible outcome for the individual seeking services at the lowest level of service delivery. We encourage each person to weigh the pros and cons of both options and then decide only after being fully informed of all the possible consequences both good and less desirable as a result of billing insurance for behavioral health and drug and alcohol treatment. 

The following limitations are important to consider before you choose a treatment program based upon insurance coverage alone:

·        Type of Coverage of Your Insurance

·        Out of Pocket Expense Limits of Insurance

·        Copay  Percentage  Amounts

·        Percentage of Coverage

·        Your current out of pocket expense limit amounts

·        Medical necessity definition as defined by your specific insurer.

·        Overall cost of a treatment program in comparison to paying with insurance

·        The potential for consequences and resulting stigma from having a drug and alcohol abuse or dependence diagnosis on your insurance record.

·        Whether or not your insurance company will cover court mandated treatment unless “medically necessary.”1

You will have to admit having a problem controlling alcohol or other drugs to meet some definitions. Unless you really believe you have a problem with alcohol or other drugs and your clinician is able to find the criteria to give a diagnosis of chemical dependency you may not be covered for some mandated treatment at all. 2

Some other important factors to consider before choosing your provider of diversion:

·       Not all insurance plans will cover your behavioral health treatment and you could get stuck with a bill that is much higher if referred to the insurance accepting provider who charges more. A recent study revealed the average out of pocket expense for Oregonian’s privately insured was around $8000.00. Some Alcohol and Other Drug treatment agencies like Teras charge less for our regular prices than you may pay out of pocket at your insurance covered providers. You may even end up paying for all your services and at higher rates because the out of pocket expense limit was not met before or during the treatment episode and you were referred to a provider that charges based upon allowed insurance payment rates at much higher costs. Transferring midstream in your diversion may cause you to stay in treatment much longer than needed to meet abstinence requirements and the ADES may charge you a transfer fee. You may not be allowed to complete diversion if insurance doesn't pay the balance owed to your treatment program by the time you are required to complete diversion for the court and the program refuses to release your completion report.6

·        Confidentiality: Every insurance company requires the insured to sign over rights to privacy for billing purposes. Your insurance record and documentation can in some circumstances be revealed without your consent. Court orders by a judge along with a court document called a subpoena for instance may cause you to have to give up your medical insurance record to a State or Federal court in child welfare and other specific court actions. Another court process known as discovery requires one side in a civil case to turn over any documents that the other side deems necessary for defending or representing their individual client interests or insurance agency or Worker’s Compensation claims if documents requested are relevant to the current claim and deemed necessary to determine eligibility or not.3

·        Health Insurance and Other Insurance Premiums Can Increase: Even though a DUII or other diverted criminal charge will not be on your permanent criminal record, your drug and alcohol diagnosis will be a part of your insurance record- some cases forever. If you are ever unemployed or have another need to obtain a personal insurance plan, life insurance, supplemental disability insurance, etc., the insurance application may include questions about prior mental health and alcohol and other drug treatment. Some insurance plans will charge more for a current or former diagnosis of alcohol or other drug dependency or a qualified mental illness.4

·        A Permanent Record of your Diversion Treatment May be Available to other Providers. You are doing diversion to divert the criminal charge from your accessible public record but your insurance and medical records are not applicable to diversion. The American Recovery and Reinvestment Act of 2009, Public Law No: 111-5, also known as the Stimulus Law, which allocates 19 billion dollars for electronic health records by the year 2014 requires medical and behavioral health companies to track positive outcomes to qualify for Federal Medicare and Medicaid funding by establishing Electronic Health Records(EHR’s) making it easier for health care providers to consolidate, store, retrieve and share medical information about an individual’s entire medical history.5

·        Our program is affordable for everyone to pay if you choose to opt out of insurance.

1. Medical Necessity as defined in June 2010 Aetna Behavioral Health Provider Manual

“Medically necessary services are those health care services that a practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered  effective for the patient’s illness, injury Introduction or disease.

2. From GroupHealth  Provider Manual online at https://provider.ghc.org/open/render.jhtml?item=/open/caringForOurMembers/behavioralHealth/bhs-exclusions.xml

“Members must have a diagnosis of substance abuse or substance dependence to be eligible for chemical dependency treatment services. Exclusions exist in medical coverage agreements. In addition to contractual exclusions, additional exclusions may include:  Court, school, or work-ordered treatment that is not medically necessary.  Educational and early intervention substance abuse programs, such as Alcohol Drug Information School (ADIS) (American Society of Addiction Medicine, ASAM, level 0.5). Urinalysis for drug screens, unless medically necessary, authorized by Group Health, or both.”

3. HIPAA vs 42 CFR, Part 2 Published January 23, 2013. “Information (drug and alcohol records) may be disclosed only under a unique court order meeting requirements of 42 CFR  Part 2. A subpoena is not sufficient. Both the court order and a subpoena   must be issued to compel disclosure.” Accessed August 17, 2013; http://blog.outcomesresource.com/?p=236

Permitted Uses and Disclosures http://www.goer.ny.gov/Training_Development/Resources/hipaa/helpFiles/PermittedUsesandDisclosures.htm

4. How a History of Mental Illness Affects Your Life Insurance Rates from insur.com accessed on August 17, 2013 at http://www.insure.com/articles/lifeinsurance/mental-illness.html

 5. Learn EHR Basics from HealthIT.gov accessed August 17, 2013, located at http://www.healthit.gov/providers-professionals/learn-ehr-basics

Health Information Exchange(HIE), Nationwide HIE Strategy. Accessed August 17, 2013. “To ensure all states operate under a common set of guiding principles and can communicate as a coordinated system, a national strategy on health information exchange is critical…Congress allocated $548 million to states under the State HIE Cooperative Agreement Program.”

6. Diversion Extended Six Months -Even After Successful Completion of Treatment! Show cause hearing at Multnomah County Circuit Court 11/27/2013.The individual successfully completed treatment requirements at  Avel Gordley Healing Center but their insurance hadn’t paid the balance off before the diversion time period deadline. The diversion participant needed to petition the court for an extension of diversion for another six months until they could straighten out the insurance payments because according to the participant the program would not release a completion report until fully reimbursed by the insurance company or the individual receiving services.