About Private Insurance

Teras PositionStatement on Insurance Coverage for Court Mandated Treatment Services


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

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

        Our official position at this time is that privateinsurance may not always be the best resource for alcohol and other drugdependency treatment and we will not encourageindividuals to use insurance unless absolutely necessary to ensure the bestpossible outcome for the individual seeking services at the lowest level ofservice delivery. We encourage each person to weigh the pros and cons of bothoptions and then decide only after beingfully informed of all the possible consequences both good and less desirableas a result of billing insurance for behavioral health and drug and alcoholtreatment. 

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

·       Type of Coverageof Your Insurance

·       Out of PocketExpense Limits of Insurance

·       Copay  Percentage Amounts

·       Percentage ofCoverage

·       Your current out ofpocket expense limit amounts

·       Medical necessitydefinition as defined by your specific insurer.

·       Overall cost of atreatment program in comparison to paying with insurance

·       The potential forconsequences and resulting stigma from having a drug and alcohol abuse ordependence diagnosis on your insurance record.

·       Whether or notyour insurance company will cover court mandated treatment unless “medicallynecessary.”1

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

Some otherimportant factors to consider before choosing your provider of diversion:

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

·       Confidentiality: Every insurance companyrequires the insured to sign over rights to privacy for billing purposes. Yourinsurance record and documentation can in some circumstances be revealedwithout your consent. Court orders by a judge along with a court document calleda subpoena for instance may cause you to have to give up your medical insurancerecord to a State or Federal court in child welfare and other specific courtactions. Another court process known as discovery requires one side in a civilcase to turn over any documents that the other side deems necessary for defendingor representing their individual client interests or insurance agency orWorker’s Compensation claims if documents requested are relevant to the currentclaim and deemed necessary to determine eligibility or not.3

·       Health Insurance and Other Insurance Premiums CanIncrease: Even though a DUII or otherdiverted criminal charge will not be on your permanent criminal record, yourdrug 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 insuranceplan, life insurance, supplemental disability insurance, etc., the insuranceapplication may include questions about prior mental health and alcohol andother drug treatment. Some insurance plans will charge more for a current orformer diagnosis of alcohol or other drug dependency or a qualified mentalillness.4

·       A Permanent Record of your Diversion Treatment May be Availableto other Providers. You are doing diversionto divert the criminal charge from your accessible public record but yourinsurance and medical records are not applicable to diversion. The American Recovery andReinvestment 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 year2014 requires medical and behavioral health companies to track positiveoutcomes to qualify for Federal Medicare and Medicaid funding by establishingElectronic Health Records(EHR’s) making it easier for health care providers toconsolidate, store, retrieve and share medical information about anindividual’s entire medical history.5

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

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

“Medically necessary servicesare those health care services that a practitioner, exercising prudent clinicaljudgment, would provide to a patient for the purpose of preventing, evaluating,diagnosing or treating an illness, injury, disease or its symptoms, and thatare (a) in accordance with generally accepted standards of medical practice;(b) clinically appropriate, in terms of type, frequency, extent, site andduration, and considered  effective forthe 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 diagnosisof substance abuse or substance dependence to be eligible for chemicaldependency treatment services. Exclusions exist in medical coverage agreements.In addition to contractual exclusions, additional exclusions may include:  Court, school, or work-ordered treatment thatis not medically necessary.  Educational and early intervention substanceabuse programs, such as Alcohol Drug Information School (ADIS) (AmericanSociety of Addiction Medicine, ASAM, level 0.5). Urinalysis for drug screens, unless medically necessary, authorized byGroup Health, or both.”

3. HIPAA vs 42 CFR, Part 2 Published January 23, 2013. “Information (drug and alcohol records) may bedisclosed only under a unique court order meeting requirements of 42 CFR  Part 2. A subpoena is not sufficient. Both thecourt order and a subpoena   must beissued 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 LifeInsurance Rates from insur.comaccessed 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 HIEStrategy. Accessed August 17, 2013. “Toensure all states operate under a common set of guiding principles and cancommunicate as a coordinated system, a national strategy on health informationexchange is critical…Congress allocated $548 million to states under the StateHIE Cooperative Agreement Program.”

6. Diversion Extended Six Months -Even After SuccessfulCompletion of Treatment! Show causehearing at Multnomah County Circuit Court 11/27/2013.The individualsuccessfully completed treatment requirements at  Avel Gordley Healing Center but their insurancehadn’t paid the balance off before the diversion time period deadline. The diversionparticipant needed to petition the court for an extension of diversion foranother six months until they could straighten out the insurance paymentsbecause according to the participant the program would not release a completionreport until fully reimbursed by the insurance company or the individualreceiving services.