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 this treatment this article will go into the details of that question. Answer = Yes, but it requires taking certain steps, and even with the correct steps, not all insurance companies will cover the cost.
Insurance Coverage for Ketamine Infusions
Factors that play a role
Have you met your health insurance deductible for the year? 51% of American working adults have high deductible insurance plans. [1] Are you one of the 51%? If you haven't met your deductible Step 1 would be to met your insurance deductible.
Are ketamine infusions covered by your insurance company? Do the treatments need to be done in network?
Can you demonstrate with medical documentation that you’ve tried and failed two to three conventional treatments for your diagnosis? 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.
Do you have good out-of-network benefits? We are considered an out-of-network provider and many insurance plans have allowances that will allow a portion to be covered if you have good out-of-network benefits.
Do you have a PPO (preferred provider organization) insurance plan or an HMO (health maintenance organization) insurance plan? If you have a PPO plan there is a higher likelihood of getting reimbursed.
How long have you been with your current insurance plan? If it's been a short time then based on observational data from our clinic it seems like your insurance is going to be less likely to 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 and make sure you are taking the right steps for reimbursement with your insurance. Each insurance company is a little different with what they want in order for the insurance company to cover the cost of treatment. It helps if your insurance company is already in possession of past documentation for the diagnosis you are wanting to treat with ketamine.
When you submit your request to get an off-label medication covered it helps to show the insurance company that there is ample research showing that it helps with the condition you are suffering from. Spend the time to find that research and have it available for the insurance company. If there isn't good research to back up what you are looking to treat then that decreases the chances your insurance will cover the 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.
Steps patients will need to take to get reimbursed by your insurance
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. This process does require you to be organized and submit things in an organized timely way to increase the likelihood of getting reimbursed.
Background on FDA approval for Ketamine
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. Ketamine was first used as an anesthetic. It was approved by the FDA in 1970 as an anesthetic and analgesic in operating and emergency rooms under the brand name Ketalar.
Research on the efficacy of ketamine for the treatment of depression and other mood disorders is ongoing. As more clinical data is published it's clear that ketamine is a potent medication with many uses. The list of diagnoses that ketamine improves continues to grow. We look forward to additional research that meets the standards insurance companies utilize to cover the medical cost of ketamine infusions.
