FMLA Insurance For Addiction Treatment Coverage

As we’ve covered in the past, health insurance coverage can be very confusing – and very understandably so. Different insurance providers and plans may cover different rehab services, for one. Moreover, such laws as FMLA are practically immensely helpful, but only complicate matters more when you’re looking for concise answers. To address this, we at Harmony Ridge Recovery find it fitting to explain FMLA rehab coverage in this article, step by step.

From what FMLA is to which addiction types and treatment services it covers, we have gathered some comprehensive resources you will hopefully find of use. If this sounds relevant to your concerns, please read on.

Starting with the fundamentals, here we may explain what exactly FMLA is. This will help us make a crucial distinction; FMLA is not, in and of itself, health insurance. This may seem confusing, but we promise it will make perfect sense within a few short paragraphs.

What is FMLA?

Abbreviated as FMLA, the Family and Medical Leave Act is a federal law passed in 1993. The law aimed to provide employment stability to families in need, enshrining into law that employees may take “up to 12 weeks of unpaid, job-protected leave per year”.

As such, FMLA first addresses employers. In line with the Affordable Care Act (ACA, sometimes referred to as Obamacare) cementing strong incentives for employers to provide health insurance to their employees, FMLA “requires that [employees’] group health benefits be maintained during the leave”.

Thus, it should now be clear that FMLA rehab coverage doesn’t equate to health insurance coverage. Rather, FMLA ensures you can take a leave to attend rehab without fear of losing your job. Covering your rehab costs will then fall on your existing employee insurance coverage, which FMLA maintains during your leave.

Who Does FMLA Apply To?

That said, FMLA doesn’t apply to all employers. It still applies to the majority, including:

• All public agencies
• All public and private elementary and secondary schools
• Companies with 50 or more employees

In addition, it comes with specific employee eligibility criteria. Namely:

• They must have worked for their employer for at least 12 months, and for at least 1,250 hours over the past 12 months, and
• They must work at a location where the company employs 50 or more employees within 75 miles

So, as long as you and your employer both meet these criteria, FMLA can apply to you.

The Department of Labor (DOL) also specifies that “special rules apply to employees of local education agencies” and that military family leave provisions “afford FMLA protections specific to the needs of military families”. If you’d like to know more about these cases, you can visit the link to the official DOL website above.

What FMLA Covers

Now, FMLA rehab coverage is an even more specific matter. That’s because FMLA specifically covers, according to the DOL:

• The birth of a child and to care for the newborn child within one year of birth;
• The placement with the employee of a child for adoption or foster care and to care for the newly placed child within one year of placement;
• Caring for the employee’s spouse, child, or parent who has a serious health condition;
• A serious health condition that makes the employee unable to perform the essential functions of his or her job; or
• Any qualifying exigency arising out of the fact that the employee’s spouse, son, daughter, or parent is a covered military member on “covered active duty”.

To “care for a covered servicemember with a serious injury or illness if the eligible employee is the servicemember’s spouse, son, daughter, parent, or next of kin (military caregiver leave)”, FMLA makes a single exception for servicemembers, providing the option of up to 26 weeks of leave.

Most of these cases should be clear, with the exception of what constitutes a “serious health condition”. These can include mental health conditions, such as:

• Memory disorders
• Disorders such as severe depression, severe bipolar disorder, and schizophrenia.
• Post-traumatic stress disorder (PTSD)

In addition, they can include physical health conditions like:

• Cancer
• Multiple sclerosis
• Nervous system disorders
• Pneumonia
• Pregnancy

As such, FMLA can be used for rehab, as long as:

• It is diagnosed by a professional who refers the addicted individual to treatment,
• Addiction constitutes a serious health condition, as defined by the FMLA, which prevents the individual from carrying out their work, and
• The individual requires leave for treatment and not because of substance use, as Cornell Law School notes.

Does FMLA Always Protect Employment?

Finally, as regards FMLA rehab coverage in particular, there is one crucial note to make. Taking FMLA leave in itself is protected, so employment status is protected in this case. As Cornell Law School argues in the document linked above, “the employer may [also] not take action against an employee who is providing care for a covered family member receiving treatment for substance abuse”. Both of these cases are clear-cut.

However, Cornell Law School also rightly argues that “treatment for substance abuse does not prevent an employer from taking employment action against an employee”.

They explain this case as follows:

“The employer may not take action against the employee because the employee has exercised his or her right to take FMLA leave for treatment. However, if the employer has an established policy, applied in a non-discriminatory manner that has been communicated to all employees, that provides under certain circumstances an employee may be terminated for substance abuse, pursuant to that policy the employee may be terminated whether or not the employee is presently taking FMLA leave.”

So, an employer may not fire an employee for taking FMLA leave. However, they may still fire an employee, even during FMLA leave, if established policies prohibit substance abuse.

With FMLA hopefully clear to you, now we can proceed to analyze rehab in more depth. Specifically, we may start with how you can apply for rehab under FMLA.

As outlined above, FMLA will not cover your actual rehab expenses. Rather, it will allow you to take up to 12 weeks of unpaid leave to receive treatment. The insurance which will cover your rehab will be the one that covered you while you were working, as FMLA will maintain it during your leave.

To get started with FMLA, you will first need to visit a healthcare provider. Once they diagnose that your case of addiction qualifies for FMLA, in line with the above criteria, they will make arrangements with your employer and help guide you through the rest of the process.

How to Check If Your FMLA Insurance Covers Rehab

Next, you may check for three distinct factors:

• Whether your need for rehab qualifies for FMLA, as highlighted above,
• If your existing health insurance covers rehab, and more specifically,
• Which exact types of rehab services your existing health insurance covers.

If all three apply to you, you may begin rehab under FMLA once you’re referred. Ideally, you should check all three with certified healthcare providers and your health insurance providers, as an array of factors and provisions may affect final coverage.

FMLA Rehab Coverage – Scope and Treatments

Still, here we can outline the fundamentals of FMLA eligibility and health insurance rehab coverage. Please review the following carefully, and then check with all relevant parties to ensure these apply to you.

If you do choose Harmony Ridge Recovery, our representatives will gladly provide any additional information you need and make needed arrangements on your behalf.

Which Addiction Treatment Does Your Insurance Cover?

Initially, most health insurance plans cover rehab and mental health services, as federal law mandates. The Mental Health Parity and Addiction Equity Act (MHPAEA) extends the Mental Health Parity Act (MHPA) protections to substance use disorders, effectively covering:

• Clinical and behavioral services included in outpatient cocaine rehab
• Detox and inpatient programs offered through any fentanyl detox center
• Rehab services offered in heroin rehab centers
• Ambien rehab services
• Barbiturates rehab services
• Benzo rehab programs
• Detox and treatment programs offered in any marijuana rehab center
• Services offered by any stimulants addiction rehab center
• Rehab services offered by any opiate rehab center
• Rehab services of any meth rehab center West Virginia has to offer

While MHPAEA “does NOT require large group health plans or health insurance issuers to cover [rehab] benefits”, ACA does as it “requires coverage of mental health and substance use disorder services”. As such, all of the above addiction treatments are, in the vast majority of cases, eligible for some coverage.

What Types of Programs Does FMLA Cover?

Now, FMLA rehab coverage will typically cover services that are deemed medically necessary. Your existing health insurance will likely cover more services than the ones eligible for FMLA, so for the rest you will have to make arrangements with your employer.

For instance, inpatient services are explicitly covered by FMLA and virtually all health insurance plans. However, subsequent outpatient programs may also be covered by your insurance but not qualify for FMLA, or they may extend beyond the 12 weeks FMLA accounts for. In such cases, your insurance may cover rehab services, but you will still need to make arrangements with your employer for non-FMLA services and longer leave.

To better explain this, let us go through different rehab programs and examine the coverage of each.

#1 Inpatient Programs

Just as with detox, Inpatient programs entail hospitalization. As such, they explicitly qualify for FMLA coverage if healthcare providers deem them necessary. Health insurance plans will typically cover them as well, as they constitute the first crucial step to recovery. Thus, inpatient drug rehab in WV and beyond will typically qualify for both.

However, it’s crucial to note program duration as well. While how long detox and inpatient programs will take varies, in total the two can last considerably. Detox tends to take 1-2 weeks, extending to 3-4 weeks in severe and specific cases, and inpatient programs may last for 1-3 months. So FMLA rehab coverage may not be able to extend to the maximum of ~16 weeks those two may require.

#2 Partial Hospitalization Programs

Typically offered as a step-down service for cases where some hospitalization is needed, Partial Hospitalization Programs (PHPs) also qualify for both FMLA and health insurance coverage. So as regards eligibility, virtually any partial hospitalization program West Virginia has to offer will fall under the umbrella of both.

Here too, a notable distinction lies in duration; PHPs tend to last for 2-4 weeks, depending on the case. Therefore, they may qualify for FMLA but extend beyond its duration, especially if they follow detox and inpatient programs. Still, the best-case scenarios of such journeys would be an FMLA-fitting 7 weeks; 1 for detox, 4 for inpatient treatment, and 2 for PHP.

#3 Outpatient Programs

From this phase onward we must make some clarifications, specifically as regards the nature of programs past PHPs.

Intensive Outpatient Programs (IOPs) and Outpatient Programs (OPs) typically follow hospitalization, and they may fall outside of FMLA eligibility if they’re not necessary for the individual to function sufficiently. In other cases, such programs may last longer than FMLA provides, as IOPs may last for 1-4 months by themselves. However, you may no longer need FMLA rehab coverage at this stage, and your health insurance will often still cover the costs of such programs.

For this phase, any intensive outpatient program West Virginia has to offer will allow you to live at home, and many will focus on you maintaining employment by flexibly arranging for therapy. With this in mind, as long as your employer takes no action against you after your FMLA leave, you may not need additional time away from work. Moreover, IOPs still provide behavioral therapy, which health insurance will typically cover.

#4 Sober Living Homes

The final step of rehab, and often a component of aftercare programs, comes in sober living homes. These programs offer housing for those in need, and a welcoming environment where the individual resides with their peers, maintains abstinence, and reintegrates into everyday life. In our experience, programs for sober living WV offers have demonstrable efficiency – and research confirms this, as the linked article shows.

However, sober living is typically not covered by either FMLA or health insurance. This is a crucial note to make, and also one that warrants explanation.

First, as regards FMLA rehab coverage, sober living homes tend to last too long. Stays typically last for at least 3 months, which is already too long a journey for FML to cover, but can extend to 18 months or more. In addition, sober living homes typically do not provide medical care, which doesn’t let them qualify for FMLA.

As regards health insurance coverage too, most rehab coverage will not extend to sober living homes. This is for similar reasons as the above, as American Addiction Centers (AAC) explains:

“While sober living homes are designed to help people recover from addiction in a safe and supportive environment, they are not considered treatment facilities.”

With all these crucial distinctions in order, you may still have questions as regards final rehab coverage and costs. While both tend to vary too much for us to provide solid, universal numbers, here we may cover the fundamentals for your convenience.

What Is the Full Cost of Rehab Without Insurance?

First, rehab costs tend to be very steep; rehab often requires specialized medical equipment and thorough medical and psychiatric services for extended periods of time. As such, most cases of addiction tend to be partially covered by FMLA rehab coverage in terms of duration, and partially or fully covered by health insurance as regards costs.

While only used as a point of reference, here we may cite the typical full costs of rehab that DrugHelpline provides:

• Drug Detox (30-day): $240–$850 per day
• Residential Treatment (varies): $5,100–$80,000
• Intensive Outpatient (30 days): $3,100–$10,000
• Outpatient Care (3 months): $1,450–$10,000

Notably, these numbers exclude PHPs, sober living homes, and any additional aftercare programs one may opt for. So evidently, few can cover the full cost of rehab out of pocket – making health insurance coverage invaluable.

Can a Family Member Pay For Your Treatment?

Thankfully, most rehab centers will also offer the option of arranging for a family member or loved one to pay for the rehab of another. This option does tend to require arrangements, however, typically so that the paying individual knows the funds are being used as intended.

If you choose Harmony Ridge for your rehab journey, our representatives will be more than happy to explore this option with you and make the necessary arrangements for your convenience.

Other Health Insurance Providers That Harmony Ridge Recovery Accepts

Still, such options aside, you may still be concerned about initial FMLA rehab coverage under your existing health insurance. In such cases, you can rest assured that Harmony Ridge accepts all major health insurance providers, including:

• Humana Insurance
• Blue Cross Blue Shield
• TRICARE Insurance
• PEIA Insurance

In addition, especially in cases where you still need to cover some expenses out of pocket, our representatives will be happy to review your coverage for you and explore self-financing options with you. If you need any such assistance, please contact us; our teams are available 24/7 at (855) 942-3797.

Health insurance coverage is a complicated matter, and so are such laws as FMLA. Unfortunately, this kind of complexity can discourage individuals from seeking help to deal with addiction, even if they deeply understand they need it.

With this in mind, we hope this article offered you some clarity and alleviated your concerns. At Harmony Ridge, it is our moral mission to make addiction treatment clear, welcoming, and affordable, without ever compromising on the quality of our services. If you’re now reassured and ready to start your journey to a new life, or if you still have questions, please contact us today. We will be more than happy to assist you further and help you reclaim the life you deserve.

What is considered a “Serious Health Condition”?

To be eligible for FMLA leave, you need to have conditions that either require an overnight stay in a medical care facility, conditions that incapacitate either you or your family members, or chronic conditions that cause periods of incapacitation for you or your family members. These conditions also need to require treatment by a healthcare provider at least twice a year. Lastly, pregnancy also qualifies as a serious health condition, as do any prenatal medical appointments, morning sickness, and medically-required bed rest.

Do I need to prove that I have a serious health condition?

Yes. You will need to provide medical certification for any issues that may prompt you to take FMLA leave. Your employer is legally obligated to allow for at least 15 calendar days for you to provide them with the necessary documentation. The certification itself needs to come from a licensed medical professional.

Do I need to provide my employer with my medical records?

No. Under no circumstances are you required to provide your employer with your medical records. All you need to do is provide them with sufficient medical facts that prove that you have a serious health condition.

Can my employer contact my healthcare provider and get information about my serious health condition?

Under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations, the only information that your employer may acquire from your healthcare provider is any information necessary to authenticate and clarify your medical certification. Your employers may not ask the healthcare provider for any other information than the one present on the medical certification form. Furthermore, your direct supervisor may not contact your healthcare provider directly. That said, your employer may get the information if you provide them with written authorization.

Is it possible to take FMLA leave due to domestic violence?

Yes, under certain circumstances. If you need to be hospitalized or experience post-traumatic stress due to the effects of domestic violence, you may be eligible for FMLA leave. You may also be able to benefit from FMLA leave if you need to care for a qualifying family member with a health condition that resulted from domestic violence. This usually includes a number of mental health issues that need to be treated at a specialized treatment center.

Does my employer need to pay me when I take FMLA leave?

No, as FMLA only requires unpaid leave. That being said, you may be able to elect to use some of your paid sick/family leave days to account for some of the FMLA leave periods. Your employer might also require you to do so. However, when you do use paid leave for an FMLA-covered reason, the entire leave is FMLA-protected.

Can my employer change my job position after I return from FMLA leave?

Yes and no. Under the FMLA rules, your employer is required to return you to the same job or an equivalent one. This is where it gets a bit “tricky”. An equivalent job must offer the same shift/general work schedule and can’t significantly increase the distance between your home and the workplace. It also needs to involve similar duties, status, and responsibilities, as well as offer identical benefits (health insurance, pension, sick leave, etc.).