Will Insurance Cover My Ketamine Treatments?
Article Summary: If you are wondering if your insurance will cover ketamine treatments at our clinic or other clinics that offer ketamine treatments this article will go into the details of that question. Answer = sometimes yes and it almost always requires certain steps as determined by your health insurance policy.
Most pertinent questions regarding health insurance coverage for ketamine infusions
Q: Have you met your health insurance deductible for the year?
A: 51% of American working adults have high deductible insurance plans. [1] Are you one of the 51%? Ketamine infusions wouldn't be covered until after you've met your deductible.
Q: Will ketamine infusions be covered by your insurance company after you've hit your deductible?
A: My experience is 90% of the time your health insurance plan will not cover the cost of ketamine infusions. Health insurance companies tends to be conservative when determining policy on how health insurance policies are paid out.
Q: Can you demonstrate with medical documentation that you’ve tried and failed two to three conventional treatments for your diagnosis?
A: If you haven’t tried two to three conventional treatments with FDA-approved modalities for your diagnosis the likelihood of your insurance covering the cost of an off-label ketamine infusion is lower.
Q: Do you have good out-of-network benefits?
A: Restorative Health is considered an out-of-network provider and some health insurance plans have allowances for coverage.
Q: Do you have a PPO (preferred provider organization) insurance plan or an HMO (health maintenance organization) insurance plan?
A: If you have a PPO plan there is a higher likelihood of getting reimbursed.
Q: How long have you been with your current insurance plan?
A: If it's been a short time then it's less likely your insurance will cover the treatments? If you have been with your insurance a long time and have a specific case manager that you have worked with before it makes sense to connect with them and get your ducks lined up. This ensures you are taking the right steps for reimbursement with your insurance. Each insurance company is a little different with what they require in order for the insurance company to cover the cost of treatment.
If you can answer yes to most of these factors then it's worth spending your time completing the process to get reimbursed from your insurance. If you answered no to most of these factors then I recommend you make it so you can say yes to most of these questions before taking the steps to get reimbursed by your insurance. If you have a health savings account we do accept credit cards tied to those accounts and can email you a receipt.
Tools that increase the likelihood insurance will cover ketamine infusions.
Superbill Example
This is an example of what a superbill looks like. A superbill is an itemized receipt that is submitted to health insurance companies for reimbursement for medical expenses. The process works the smoothest if you remember to ask for and receive an electronic copy of your superbill at the end of your appointment and then immediately submit to your insurance company. Many health insurance companies' policy require submission of superbills within 90 and sometimes 30 days to qualify for reimbursement.
Background on FDA approval for Ketamine
Ketamine was approved by the FDA in 1970 as an anesthetic and analgesic in operating and emergency rooms under the brand name Ketalar. In recent years ketamine infusions have been changing the lives of people who struggle with medically resistant depression, anxiety as well as certain types of chronic pain.
Research on the efficacy of ketamine for the treatment of depression and other mood disorders is ongoing. As more clinical data is published the data has converged on ketamine's potency with a variety of medical applications. The number of diagnoses that ketamine improves continues to grow. We look forward to additional research that meets the policy standards insurance companies utilize to cover the medical cost of ketamine infusions.
Written by William Beesley