What Is Medical Necessity?
Medical necessity is the concept that the intervention or treatment has research evidence to support its necessity to treat the condition. When treatments are deemed medically necessary, insurance companies are more likely to quickly approve them and to cover at least part of their costs.Very often, the treatment that is the least expensive but still medically necessary will be the one the insurance provider will cover.Anyone who is about to get treatment for a substance use disorder and attempting to get their Obamacare policy to cover part or all of the treatment cost should understand the following:
There are often out-of-pocket obligations that are stated in the insurance policy. Policyholders must cover these costs themselves, and the costs include copays, deductibles, and other expenses.
Policyholders must ensure the treatment they get has been approved by their provider. For instance, acupuncture, yoga classes, and luxury amenities are often not covered under insurance policies even though many rehab providers advertise them.
Policyholders must ensure that the proper referral for treatment is provided to the treatment provider. Some insurance plans require a referral from a physician for certain types of interventions, such as inpatient medical detox, whereas other interventions may only require a self-referral or a referral from nonmedical personnel.