Under New York and Federal Law, if you have insurance you have the right to receive the following addiction treatment services when medically necessary:
- Detoxification services in a hospital;
- Inpatient care in a hospital, inpatient rehabilitation or residential treatment facility;
- Outpatient care in both outpatient facilities or in your provider's office; and
- Outpatient methadone treatment, and medication for the treatment of substance use disorders, including methadone, Suboxone and Subutex, provided that you have a prescription drug benefit in your insurance plan.
Insurance Rights and Protections
As a health insurance consumer in New York State, you have the right to:
- Receive coverage determinations based upon an OASAS-approved clinical review criteria;
- Receive written notice from your health insurer if service or treatment has been denied, along with the specific reasons for denial as it applies to you, and information on how to file an appeal.
- Receive, from your insurer, the criteria used to deny treatment services;
- File an appeal with your health insurer, so long as it is within 180 days of the denial.
For more information on your rights as an insurance consumer in New York State, visit the Office of Financial Services
If your health insurer denies coverage for any addiction treatment services because it is not medically necessary, you have a right to appeal the decision with your health insurer. If your health insurer decides after an internal review, to continue to deny coverage, you have the right to an external appeal with an independent reviewer.1Continue to work with your doctor to ensure you have all the clinical information you need to explain why you still need care.
Insurer reviews their own decision to deny coverage.
- When you ask an insurer to look at a request for bedded treatment on an expedited basis and the request for bedded treatment was made at least 24 hours prior to discharge from your current level of care, you have the right to receive a decision within 24 hours.
- You have the right to have your request for substance use disorder services to be reviewed by an individual with substance use disorder treatment expertise.
- If you file an internal appeal and your health insurer still denies coverage, you have the right to receive written notification of the denial of the appeal, along with the reasons for the denial and information about your right to file an external appeal;
If your internal appeal is denied, you may file an external appeal with the New York State Department of Financial Services. They will assign an independent agent who will review the denial and make a decision that either upholds or reverses the denial.
Behavioral Health Ombudsman
New York State's behavioral health ombudsman program makes accessing and entering treatment easier. The Community Health Access to Addiction and Mental Health Care Project, "CHAMP," fights for New Yorkers facing insurance obstacles to treatment, to make sure anyone who seeks treatment--gets it, regardless of their ability to pay.
CHAMP educates New Yorkers about insurance rights and helps families navigate complex health insurance systems. CHAMP can also help resolve issues related to:
- Insurance coverage;
- Referrals to treatment services;
- Claim denials and appeals;
- Network Adequacy- an insurer's duty to offer a sufficient number of in-network options.
Contact Community Health Access to Addiction and Mental Health Care Project (CHAMP)
If you, or a loved one, have experienced insurance obstacles related to treatment or need help filing an appeal for a denied claim, call the CHAMP helpline.