Cocaine Katrina Case Summary

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Aetna does offer its members cocaine rehab and detox coverage. The level of coverage a member receives toward cocaine rehabilitation and detoxification expenses depends on his or her specific plan. A member with an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) plan receives a higher level of benefits by receiving substance abuse care through an ‘in network’ provider. Members who choose to receive rehabilitation and detoxification services from an ‘out of network’ provider are still eligible to receive benefits, just at a lower level (once their annual deductible is met).

In order for a member to be eligible to receive benefits related to substance abuse, his or her physician must determine that treatment is medically necessary. Aetna uses the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach when considering a member’s eligibility for cocaine rehab and detox coverage. SBIRT is a program designed to assist physicians in determining medical
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3. Referral to Treatment

Once a physician deems inpatient or outpatient cocaine rehab and detox treatment a medical necessity, Aetna will cover costs related to treating cocaine addiction.
Aetna’s Coverage Varies

The amount that Aetna pays toward cocaine rehabilitation and detoxification treatment services depends on the member 's plan.

Some of the cocaine addiction services that Aetna covers include:

Intensive Outpatient Programs Residential Treatment Centers Inpatient Admissions Outpatient Detoxification Partial Hospitalization Programs

If a member meets the diagnostic criteria for cocaine addiction, as well as a mental health condition, this is considered a dual diagnosis (co-occurring disorders). Some of the health plans that Aetna offers have reasonably good inpatient coverage for its members who have co-occurring

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