Meritain Health Insurance Coverage for Substance Abuse Treatment

Meritain Health is a third party administrator of self-funded health insurance plans for companies nationwide. They are a subsidiary of Aetna Insurance and its parent company CVS. A self-funded plan refers to insurance that an employer fully pays for as a benefit to company employees. The employer doesn’t pay a premium to an insurance company, instead they cover the cost of employee medical care themselves.

A third-party administrator sets up and manages the healthcare benefits for the employees, processes insurance claims and manages billing and payments for services to providers. They can also connect a self funded plan with a provider network if they need one.

Meritain Health has been in business since 1983 and has more than 1.5 million members. Most company employers purchase the Aetna Choice POS 11 plan to offer their employees because it gives them access to Aetna’s national network of 1.6 million healthcare providers and more than 350,000 behavioral health providers.

Meritain Health is the only third party administrator that can offer access to this Aetna network.

Does Meritain Health Cover Addiction Treatment?

Self funded employer plans are not required to cover addiction or mental healthcare, but if they do, they must follow the Mental Health Parity Act and cover it at the same level as other medically necessary services.

Your employer’s plan may include mental health and rehab coverage, but it may not, so it’s very important to check with your company’s benefits manager before you commit to a treatment program. You may also need to stay within a specific provider network in order to use your employer coverage.

What Inpatient Rehab Options Does Meritain Health Cover?

If your insurance plans covers inpatient rehab, you may have coverage for services like medical detox and inpatient or residential care.

Detoxification that removes drugs from the body may involve the use of medication assisted treatment (MAT) medications to treat and reduce withdrawal symptoms. Methadone, naltrexone, and buprenorphine are often used as MAT medications. The goal of medical detox is to give you a clean start and help you stay safe and as comfortable as possible during the process.

With inpatient rehab, you are treated in a clinic or hospital; with residential rehab treatment, you are treated in a non hospital facility that usually has a home like setting. Both inpatient and residential treatment options offer 24/7 supervision and care.

Inpatient treatment will often last two weeks or fewer, although some hospitals have longer term programs. Residential treatment typically lasts 28 30 days and possibly longer. Patients who have a dual diagnosis, with both substance abuse and another mental illness being present together, require integrated care that addresses both their mental health and substance use.

Does Meritain Health Cover Outpatient Treatment?

Your insurance plan may include a variety of outpatient treatment options. For example, there are partial hospitalization programs, intensive outpatient programs and regular outpatient programs.

Partial hospitalization programs (PHP), also called “day treatment,” usually involve at least 20 hours of treatment per week, with sessions held 4-5 days per week. There are no overnight stays. A typical length for PHP treatment is three to four weeks, but it can last up to several months.

Intensive outpatient substance abuse rehab treatment typically involves nine to 20 hours of treatment per week, and these hours are spread over three to five days. Ninety days of IOP treatment are most often recommended.

In general outpatient programs, group addiction education and counseling sessions usually take place in a clinic or rehab setting once or twice a week. Individual sessions are usually offered as needed, on a selective basis.

Does Addiction Treatment With Meritain Have to Be In Network?

The Aetna Choice POS (Point of Service) II plan, used by about 90% of Meritain insurance members, allows patients to use either the Aetna network of service providers or out of network providers.

Sometimes an in network provider may not be close by, or convenient, or there may be an urgent need. In such cases, an out of network option makes sense. You’ll want to make sure they accept your insurance coverage, as not all providers will.

However, out of network providers will generally cost more, and you may have to pay the additional cost yourself. Unlike when using in network services, claims and billing related to out of network providers are not handled by Meritain.

Also, while approval for coverage of some services may be required when using either an in network or out of network provider, an out of network provider would not automatically process your request for approval. You would likely have to handle that on your own.

When using an in network provider, your primary care doctor would process your request for approval when needed.

Are There Special Features Available from Meritain Health?

Employers who choose the popular Aetna Choice® POS II network can offer employees a variety of specialized services. These tools help support your overall health and therefore have an impact on your mental health and triggers for substance use disorder. For some services you may need pre certification performed by the medical management team.

Your physician must pre certify certain services that go beyond a standard physician office visit. This can include non emergency admissions or elective ambulatory surgery. It may also include diagnostic procedures and continuing care services for conditions like substance use disorders and mental health conditions. The medical management team will review the treatment plan against standard guidelines to ensure the procedure or treatment is medically necessary. Your member’s services booklet has a list of all services that require pre certification.

The Aetna Choice® POS II network has over 776,000 physicians across more than 6,100 hospitals to provide specialized care for nearly every concern. Aetna has an Institutes of Quality and Institutes of Excellence programs throughout their facilities. The Institutes of Excellence program offers access to a network of high performing hospitals that help improve patient outcomes. The Institutes of Quality is a designation for healthcare providers that meets certain quality standards.

Within this network of Institutes Aetna has identified high levels of care in bariatric care and cardiac care along with orthopedic care and behavioral health. The Institutes of Quality Network for Behavioral Health provides beneficiaries with specialized treatment for substance use and mental health conditions. Your benefits can also include virtual and in person behavioral health care to help address mental health conditions like depression and anxiety disorders.

Your insurance benefits may include a telemedicine service available to you 24/7/365. You’ll have access to qualified physicians over the phone and online as well as through an app. Telehealth and virtual primary care options provide help when you’re unable to see your primary physician in person or you are traveling or live in rural areas without a large network of physicians. The Aetna Choice® POS II network also includes Minute Clinic and Health Hub walk in locations available seven days a week so you can receive urgent care when you need it. These often have a lower cost than most urgent care facilities.

Aetna also provides wellness programs including the Healthy Merits program with resources to focus on fitness and nutrition along with financial wellness and social and emotional health. Employers can fully customize the Healthy Merits program based on the needs of their employees. They have over 400 unique wellness activities and challenges and others that can be developed. The program supports employees working from home using an accessible online or mobile app that easily integrates with wearable fitness trackers.

Aetna offers core benefits for self funded plans including an online health assessment tool to help you set health goals and identify potential health risks. The Informed Health Line offers 24/7 health information from registered nurses so you can quickly get your questions answered. Members also have access to discounts on products and services for fitness and natural therapy along with weight management and nutrition. You may also have access to Nurse Health Coaching and support services that help manage chronic conditions such as diabetes and heart disease and management for other complex situations like fertility.

Finally when you have questions about your insurance benefits or coverage you can access 24 hour support to member services. You may use the online member portal or Meritain Health app along with printed resources and customer service to get your questions answered about your health insurance benefits.