How to Actually Use Your Health Insurance for Treatment Without Getting Burned

Health insurance should make treatment easier. But in real life, it often adds confusion at the exact moment you need simplicity.

This post is a practical guide to help you understand your benefits, ask the right questions, and avoid surprise bills whether you’re looking at outpatient, detox, residential, or anything in between.

The 5 terms that matter most

If you learn nothing else, learn these:

1) In-network vs out-of-network

• In-network means the provider has a contract with your plan (usually lower cost).

• Out-of-network means no contract (often higher cost, different rules, sometimes no coverage).

2) Deductible
What you may need to pay before insurance starts sharing costs (not always required for every service, but often is).

3) Coinsurance
Your percentage after deductible. Example: insurance pays 70%, you pay 30%.

4) Copay
A fixed fee per visit (common in standard outpatient).

5) Out-of-pocket maximum
The most you should pay in a plan year for covered services (after that, insurance typically pays 100% of covered costs).

These five terms tell you whether “covered” actually means “affordable.”

Step 1: Don’t ask “Do you take my insurance?”

That question is too vague. Ask these instead:

• Are you in-network with my exact plan (not just the insurance company)?

• What level of care is covered for me right now: detox, residential, PHP, IOP, outpatient?

• Do you need prior authorization? Who submits it?

• Can you give me an estimated patient responsibility range based on my benefits?

A provider can “accept” your insurance but still be out-of-network, or covered in a limited way. Push for specifics.

Step 2: Verify benefits the right way

Benefit verification is useful, but it’s not the final word unless it includes details.

When admissions verifies benefits, ask them to confirm:

• in-network or out-of-network status

• deductible amount + how much is already met

• out-of-pocket max + how much is already met

• coinsurance or copay for the level of care

• whether prior auth is required and approved

• any limits (visit limits, day limits, medical necessity reviews)

If they can’t answer one of these yet, that’s fine, but you want a plan for how and when you’ll know.

Step 3: Understand prior authorization in plain English

Prior authorization means: your insurance wants clinical information first to decide whether they’ll cover the service and for how long.

This is normal for higher levels of care like:

• detox

• residential

• PHP

• IOP

What to know:

• approval is usually time-limited and reviewed periodically

• documentation matters (symptoms, safety risks, prior treatment history, functioning)

• getting denied doesn’t always mean “no,” it can mean “appeal with more clinical detail”

Step 4: Watch out for these common cost surprises

These are the ones that trip people up:

“Covered” doesn’t mean “free.”
Coverage can still mean deductible + coinsurance.

Out-of-network reimbursements can be weird.
Your plan may pay a low “allowed amount” and you cover the gap.

Facility fees and professional fees can bill separately.
Ask if billing is bundled or separated.

Ambulance, labs, and pharmacy can be separate coverage buckets.
Ask what’s included vs not.

Step 5: If you’re out-of-network, you still may have options

Out-of-network doesn’t always mean dead end. Depending on your plan and situation:

• Single Case Agreement (SCA): Sometimes insurance will agree to treat an out-of-network provider like in-network for a specific episode of care.

• Gap exception: If there’s no comparable in-network option available, you can request an exception.

• Out-of-network benefits: Some plans reimburse part of the cost (you’ll want the allowed amount and reimbursement percentage).

If you’re overwhelmed, ask the provider’s admissions team if they help with any of these processes.

The exact questions to ask your insurance plan

Call the number on your card. Ask for a reference number at the end of the call.

Use this script:

• Can you confirm my plan’s behavioral health benefits?

• For residential/PHP/IOP/detox/outpatient, what is my:

  • copay or coinsurance

  • deductible and how much is met

  • out-of-pocket max and how much is met

• Do these services require prior authorization?

• Are there any day limits or visit limits?

• Is this provider in-network under my specific plan name?

• If out-of-network: what is my out-of-network reimbursement and allowed amount methodology?

• Where can I find this in writing (member portal document name)?

What to gather before you call admissions

This speeds everything up:

• insurance card (front/back)

• your availability for an assessment call

• basic history (what’s happening, how long, any safety concerns)

• prior treatment history (if any)

• current meds (if any)

Where Runway Recovery fits

If you’re trying to use insurance and you want straight answers without getting bounced around, we can help you understand your options, verify benefits, and map the next step that fits your clinical needs.

Runway Recovery is also in-network with Blue Shield of California, which can significantly reduce out-of-pocket costs for eligible members.