First Health Insurance

Key Takeaways

• First Health Insurance has a historical role in American health coverage, evolving to meet healthcare economics and policy.
• It offers a range of coverage options within the ACA Marketplace, emphasizing affordable plans with comprehensive benefits.
• Inpatient coverage includes services like room and board, nursing care and medications, with specifics varying by plan.
• Outpatient services for substance misuse recovery are available, with preauthorization typically required for coverage.
• Substance misuse treatment is covered, aligning with ACA requirements and the Mental Health Parity and Addiction Equity Act.
• First Health Insurance provides a national PPO network, ensuring a wide range of in-network treatment facilities for rehab services.
• Understanding the claims process is crucial for accessing rehab benefits, with in-network providers offering cost savings and quality assurance.
• Out-of-network services may lead to higher out-of-pocket costs, emphasizing the importance of understanding insurance coverage.

The Origins and Purpose of First Health Insurance

First Health Insurance has a storied place in American history as one of the pioneering entities in health coverage. The concept of health insurance in the United States saw its early inception in the 1850s with the establishment of the Franklin Health Assurance Company of Massachusetts, which offered the first accident and health insurance policies. However, it was not until the early 20th century that health policy reform gained momentum. In 1912, Teddy Roosevelt and the Progressive Party endorsed social insurance, including health insurance, as part of their platform, marking a significant step toward the system we recognize today.

Historical Background

Modern, prepaid health insurance, where participants pay monthly premiums ahead of any medical treatment, emerged in 1929. This model was first adopted by school teachers in Dallas, Texas, who paid an annual fee for hospitalization insurance. Since then, the landscape of health insurance has continually evolved, influenced by political struggles, the expansion of organized labor and legislation such as the 1947 Taft-Hartley Act, which recognized health insurance as a condition of employment subject to collective bargaining.

First Health Insurance, as part of this historical progression, has developed a mission to provide comprehensive coverage to its members, focusing on general health and wellness. Its history reflects the broader narrative of health insurance in America, characterized by an ongoing quest to balance the needs of the insured with the complexities of healthcare economics and policy.

First Health Insurance Coverage Options

First Health Insurance offers a diverse range of coverage options to cater to individual and family health needs. For 2024, UnitedHealthcare, a key provider within the Marketplace, has emphasized the importance of affordable plans with comprehensive benefits, including $0 primary care visits, low-cost prescriptions and additional dental and vision coverage. These plans also offer reward incentives for members who engage in health-promoting activities.

The open enrollment period for these plans typically runs from November 1 through January 15, with some state-specific variations. It is important to review the coverage details, including the various types of plans available and high deductible health plans (HDHP), to determine which plan best aligns with health care needs and the financial situation.

Inpatient Coverage

First Health Insurance provides inpatient coverage that is integral to its suite of healthcare services. The coverage specifics are designed to cater to the needs of patients requiring hospital stays for various treatments, including substance misuse rehabilitation. Inpatient coverage typically encompasses services such as room and board, nursing care, medications and other hospital services and supplies. The policy details and extent of coverage can vary based on the individual plan and contract renewal terms.

For Medicare Advantage enrollees, First Health Insurance adheres to the two-midnight rule regulation, which stipulates coverage for an inpatient admission when the patient’s stay crosses two midnights. Medical necessity is a key factor in determining coverage, with the insurer reviewing clinical documentation and applying appropriate Medicare guidelines, InterQual criteria, or internal coverage criteria. This ensures that inpatient services are not only necessary but also meet the required standards for insurance coverage.

Outpatient Coverage

First Health Insurance recognizes the critical nature of treating substance use disorders and offers a variety of coverage options, including outpatient services. Outpatient treatment is a vital component of the continuum of care for individuals seeking recovery from drug and alcohol addiction. It allows for flexibility and can enable individuals to maintain their daily responsibilities while receiving treatment.

As part of its behavioral health benefits, First Health Insurance provides access to a network of treatment facilities, ensuring that policyholders receive quality care tailored to their needs. This includes a range of outpatient services such as counseling, therapy sessions and ongoing support, which are essential for long-term recovery. The coverage specifics, however, may vary based on the individual policy and the level of care required.

Substance Abuse Treatment Coverage by First Health Insurance

First Health Insurance, now part of Aetna since 2013, operates nationwide with a significant presence in states like Michigan and Colorado. It covers approximately 5.5 million individuals, providing a robust network of treatment options for substance misuse. The Affordable Care Act mandates that substance misuse treatment is considered an essential healthcare service, which means that First Health, like all insurers in the Marketplace, must cover at least a portion of the costs associated with alcohol and drug rehab services.

Insurance coverage for substance misuse treatment is also reinforced by the Mental Health Parity and Addiction Equity Act of 2008, which mandates that health insurance companies provide coverage for addiction treatment on par with medical and surgical care. First Health Insurance aligns with these regulations, ensuring that members receive the necessary care for drug and alcohol rehabilitation. .

• Drug Rehabilitation: First Health Insurance coverage for drug rehabilitation includes access to a variety of treatment levels, such as outpatient programs, inpatient rehabilitation and detoxification services. Covered treatments may include cognitive-behavioral therapy, various forms of talk therapy and medications that are part of addiction treatment programs.
  
• Alcohol Rehabilitation: Private health insurance plans, like First Health, often cover a portion of the costs associated with alcohol addiction treatment. This can include therapy sessions, counseling and some prescription medications. Coverage may be subject to certain conditions, such as the medical necessity of the treatment and may include various levels of care, from detoxification and inpatient rehabilitation to outpatient services and ongoing therapy.

It is advisable for members to verify their coverage details, as the extent of coverage can vary based on individual plans and state regulations. For personalized information, members can contact First Health directly or utilize resources such as Northbound Treatment’s insurance verification form to clarify their entitlements

The Claims Process with First Health Insurance for Rehab Services

To make a claim with First Health Insurance for rehab services, you typically do not need a referral, which simplifies the process of entering a treatment program. To initiate a claim, you should first verify your coverage by checking with First Health or the treatment facility. Upon admission to a rehab center, you may be required to pay a copayment.

The facility will then coordinate with First Health to manage medical claims on your behalf. For those with First Health Insurance, the benefits of utilizing in-network providers for addiction treatment include a broader range of options and potentially lower costs. However, it’s essential to be aware of your plan’s specific coverage details, including any deductibles, copayments and coinsurance responsibilities.

Step-by-Step Guide to Filing a Claim with First Health Insurance

Filing a health insurance claim with First Health Insurance involves several key steps to ensure that your medical expenses are covered. Here is a simplified guide to help you navigate the process:

1. Review Your Policy: Before filing a claim, thoroughly review your First Health Insurance policy to understand your coverage and any preauthorization requirements for the services you received.

2. Gather Necessary Documentation: Collect all relevant documents, such as medical bills, receipts and any other paperwork that supports your claim.
   
3. Complete the Claim Form: Fill out the First Health Insurance claim form, which may be the standard CMS-1500 form used by many insurers. Ensure all information is accurate and complete to avoid delays.
   
4. Submit the Claim: Send the completed claim form along with the supporting documentation to First Health Insurance. You may be able to submit these documents via mail, fax, or possibly through an online portal if available.
   
5. Track Your Claim: Keep a record of your claim submission and follow up with First Health Insurance to check the status. This will help you address any issues promptly if your claim is delayed or denied.

6. Review the Explanation of Benefits (EOB): Once processed, you will receive an EOB from First Health Insurance detailing what was covered and any amounts you may owe.
   
7. Address Denials or Discrepancies: If your claim is denied or if there are discrepancies, review the reasons provided and consider filing an appeal. You may need to provide additional information or clarification to support your appeal.

It’s important to file your claim in a timely manner and to keep detailed records throughout the process. If you encounter difficulties, First Health Insurance’s customer service can assist you with any questions or concerns you may have.

Handling Claim Denials and Appeals

Dealing with a health insurance claim denial can be a challenging and often frustrating experience. However, understanding the appeals process is crucial for patients who face rejections of their claims by First Health Insurance. The first step in this process is to thoroughly review the EOB document to understand the specific reasons for the denial. This information is vital for crafting a detailed appeal letter that addresses the points raised by the insurer.

Patients have the right to an internal review appeal, where the insurance company re-evaluates the claim. It is essential to adhere to the insurer’s outlined timeframe for submitting an appeal, which may vary by state law. If the internal appeal is unsuccessful, an external review by a third party can be requested. This step involves a completely independent review of the claim and the insurer’s decision to deny coverage.

First Health Insurance’s Provider Network for Rehab Services

With a national reach that includes all 50 states, Puerto Rico and the District of Columbia, First Health Insurance ensures that approximately 95% of Americans have access to a network provider within 20 miles of their location. For individuals seeking drug and alcohol rehab services, First Health Insurance’s expansive network means a higher likelihood of finding suitable in-network treatment options.

The network is comprised of over 1 million healthcare professionals, including specialists in addiction treatment and is affiliated with more than 5,000 hospitals and 90,000 ancillary facilities. As part of Aetna’s family, following the merger with First Health Group Corporation and Cofinity, policyholders can expect a robust selection of treatment facilities and services.

Advantages of Choosing In-Network Providers for Rehab

Opting for in-network providers when seeking drug and alcohol rehab services can yield significant benefits, primarily in terms of cost savings and quality assurance. In-network facilities have agreements with insurance companies, which means they offer services at negotiated rates, resulting in lower out-of-pocket expenses for patients.

• Cost-Effectiveness: In-network providers have pre-negotiated prices with health plans, offering services at a lower cost compared to out-of-network options, which can lead to significant savings for the insured individual.
  
• Quality of Care: In-network facilities are typically required to meet certain standards regarding patient care and safety, ensuring a level of quality and reliability.
  
• Simplified Claims Process: Using in-network providers often streamlines the claims process, as the rates and coverage are already established, reducing the administrative burden on patients.

• Wider Acceptance: Major insurance carriers like Blue Cross Blue Shield are widely accepted, making it easier for policyholders to find an appropriate in-network facility for their rehabilitation needs.

Out-of-Network Substance Abuse Treatment Costs

Out-of-network services typically result in higher out-of-pocket expenses for patients, as insurance plans often cover less — or sometimes none — of the costs compared to in-network services. Patients may face substantial cost-sharing payments, with individuals in the top percentile spending an average of over $3,500 for out-of-network care. This financial burden can be a critical factor for those seeking treatment for drug or alcohol use disorders.

While out-of-network providers may offer specialized services or be more aligned with a patient’s treatment preferences, the decision to use such services should be weighed against the financial costs and coverage limitations. Patients are encouraged to seek guidance from insurance specialists or treatment facility navigators to make informed decisions regarding their care.

First Health Insurance Coverage for Rehab at a Glance

First Health Insurance is recognized for its commitment to providing coverage for substance misuse treatment, including drug and alcohol rehab. As part of its behavioral health benefits, First Health supports access to a variety of care levels, such as inpatient and outpatient rehabilitation services, as well as detoxification programs.

• Being a preferred provider organization (PPO), First Health allows members to choose in-network providers without needing referrals or preauthorization, offering a wide range of treatment options.
  
• The partnership with Aetna expands First Health’s ability to deliver healthcare solutions nationwide, with strong coverage networks in specific states like Michigan and Colorado.
  
• The process of entering rehab with First Health Insurance typically involves a copayment at the point of service, after which the insurance and the facility manage medical claims, with the member responsible for any remaining costs.

Drug, Alcohol and Mental Health Treatment at The Recovery Village

At The Recovery Village Rehab Centers, we take the extra steps to treat your addiction or mental health needs by offering a full continuum of care. From medical detox to rehab to aftercare, we are focused on supporting your recovery every step of the way.

Our representatives can answer your questions and guide you toward treatment in your area. Your call will be confidential and you don’t have to commit to a program to learn more about treatment options. Call today and find out how we can help you towards a healthier, happier future.