Benefit determination under managed care for substance abuse treatment clients

Care Manag J. 2001;3(2):55-62.

Abstract

The purposes of this study were to examine the process of benefit determination, approval, and variation among Substance Abuse Treatment (SAT) clients. A convenience sample of 20 SAT clients admitted to 1 of 2 treatment programs within Matrix Center were followed. Clients of clinicians who agreed to participate were given an invitation letter to hear more about the study. After informed consent, clients granted 3 interviews and gave permission for the researcher to examine client records to ascertain the benefit determination process. Referral sources were the clients' insurances, their MDs, a counselor, hospital, Employee Assistance Program, case manager, and another treatment program. Ten of the insurances were PPOs, 9 were HMOs, and 1 was a contract. All but 2 had benefits managed by a behavioral care organization (MBCO). Case managers of the MBCOs were all clinicians, most frequently ACSWs. All programs authorized outpatient care and the first approval authorized from 6 to 52 visits. From 1 to 5 different authorizations were used for each client. The co-pay ranged from $0 to $35 per visit. This study illustrates the details of how benefits for substance abuse treatment under managed care are negotiated and used.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Case Management
  • Deductibles and Coinsurance
  • Eligibility Determination*
  • Female
  • Health Services Research
  • Humans
  • Insurance Coverage*
  • Los Angeles
  • Male
  • Managed Care Programs / economics*
  • Referral and Consultation
  • Substance Abuse Treatment Centers / economics*
  • Substance Abuse Treatment Centers / statistics & numerical data
  • Substance-Related Disorders / economics
  • Substance-Related Disorders / rehabilitation*