September 1, 2022

Insurance Coverage And Ketamine Therapy

Ketamine Therapy is a rapidly growing treatment for individuals suffering from various types of mental health conditions. Treatments have repeatedly proven to significantly reduce the symptoms of mental illness for many people, often times more quickly and with less side effects than more traditional methods.

Unfortunately, despite its positive results, ketamine therapy is not officially covered by many insurance companies in the United States.

The Mental Health Crisis in the United States

In 2020, one in five adult Americans reported experiencing symptoms of mental illness. This means that tens of millions of Americans live with anxiety, depression, and other potentially debilitating conditions. The United States is in the middle of a mental health crisis.

Though the United States is making steps towards improving mental health (the roll out of emergency line 988, for example), there is still much to improve.

A critical step that can be taken is for insurance companies to cover emerging mental health treatments such as ketamine therapy, including through Medicare and Medicaid programs. This would allow millions of Americans to have access to life-changing treatments.

Why Many Insurance Companies Don’t Cover Ketamine Therapy

Insurance companies have stated a few reasons for lack of coverage, one of which is that ketamine therapy is prescribed as “off-label.”

Off-label prescribing is when a clinician prescribes a medication in a different way than was explicitly approved by the FDA. Because ketamine was approved by the FDA in 1970 as an anesthetic, but has not been re-approved by the FDA specifically for treatment of depression and anxiety, some insurers choose not to cover it. However, ketamine therapy has been used to treat mental health conditions for more than 20 years.

There has been progress made towards more FDA approvals. For example, Esketamine (an intranasal ketamine-derivative spray called Spravato) was approved by the FDA in 2019 for patients with treatment-resistant depression. Though not all insurance companies cover Spravato, it is increasing in popularity and slowly gaining more coverage.

Furthermore, research is currently promoting multiple psychedelic medicines to be granted FDA approval. This includes generic ketamine’s application in treating a number of conditions. There is hope that effective treatments like ketamine therapy will be more widely covered as FDA approvals continue to roll out.

Is Ketamine Therapy Covered by Your Insurance Provider?

Though coverage of ketamine treatment is limited, there are some options to help determine if your insurance provider will cover (or help offset the costs of) ketamine treatment. Here’s some steps you can take:

  1. Contact your insurance provider

Contact your insurance provider before starting ketamine therapy to ask if they provide any type of coverage to help reduce or cover the cost of your ketamine treatment.

Insurance coverage for ketamine therapy varies on a case-by-case basis with some providers willing to cover partial up-front costs of ketamine treatment. For example, a treatment can be designated as “an infusion of a generic drug” for partial coverage. Discussing these options with an insurance representative ahead of time can make a big difference in your available coverage.

After receiving care, your insurance provider will send an “explanation of benefits,” which details the costs of treatment and how much insurance will cover. In some cases, you’ll need to meet your deductible before the insurance provider will provide full or partial coverage of the cost of any services. This is another reason why it’s important to discuss your options with a knowledgeable representative.

  1. Discuss out-of-network reimbursement

Out of network reimbursement is when your insurance provider asks you to pay your clinical provider “out-of-pocket,” or using your own finances, with the intent of reimbursing you.

Unless expressly stated as part of your terms of agreement, most insurance providers will accept out-of-network claims for healthcare services. How these claims are paid or reimbursed is unique to each insurance provider, and depending on your coverage, you may receive a full or partial reimbursement for those services in the following weeks.

Again, it’s important to check with your insurance provider on out-of-network coverage requirements or reimbursements before seeking treatment.

  1. Provide a superbill, if requested

A “superbill” is an itemized invoice of the services rendered to the client. It also includes relevant details like the clinician’s name, and the date and type of services, as well as your own identifying client data. This acts as a “proof of service.”

Superbills are often used as part of out-of-network coverage and in cases where the insurance provider would like more information around the submitted claim. In the case of ketamine treatment, you can request a superbill from your clinical provider to share with their insurance provider at their request.

Does WellCentric Health Accept Insurance for Ketamine Therapy?

It’s possible that your insurance provider may fully or partially reimburse you for your Ketamine Therapy from WellCentric Health. After your first virtual visit, we can provide you with a superbill detailing treatment that you can submit for reimbursement.

If you’d like to check with your insurer about the possibility of out-of-network reimbursement, contact us and we’ll send you the billing codes that we use.

Other Programs That Help Reduce Ketamine Treatment Costs

HSA/FSA Accounts

Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) are both tax-advantaged accounts that allow you to set money aside for qualified healthcare expenses as designated by the Internal Revenue Service (IRS). Account owners are often issued a debit card that can be used to pay for services in person or online.

Some WellCentric treatments could be considered qualified expenses, making them potentially able to utilize HSAs or FSAs to pay for treatment. To determine if these services are covered, use your card to pay for your treatment during the checkout process. If you’re unable to make a payment with these methods, check with the card’s processor, as eligible expenses are ultimately determined by them. Unfortunately, WellCentric has no control over the outcomes.

Monthly payment plans and other financing options

Contact us to learn about our current options for payment plans that help to defer the up-front cost of your treatment. We often have options to provide you with the immediate care you need while spreading the cost over a greater time period.

The Future of Insurance Coverage for Alternative Therapies

At WellCentric, we are working with other like-minded companies to remove the barriers that prevent individuals from receiving treatment by making treatment more accessible and affordable. The more platforms, clinics, and providers that show that ketamine therapy is a safe and effective mental health treatment, the more insurance companies are aware that this is a viable treatment method worth covering.

To further help make ketamine treatment more accessible to all who will benefit, there are groups of medical specialists, patients, and their lawyers who are lobbying insurance companies to cover ketamine therapy treatments, both for mental health conditions and physical pain management. We are optimistic that effective, alternative mental health therapies will be more widely available to individuals in the future.

Current lobbying efforts

As previously posted here, Kimberly Juroviesky is the president of the Ketamine Taskforce, a non-profit organization which is working with regulators to change how ketamine is covered by insurance companies. The volunteer group is made up of patients, doctors, nurse practitioners, and patients’ lawyers.

She explains that in the long term, having ketamine treatment covered by insurance is beneficial for all sides.

“Insurance [companies] need to realize that [ketamine treatment] is less expensive than someone who’s suicidal who has to go to the hospital,” Juroviesky says. “When you’re covering a hospital bill that’s hundreds of thousands of dollars versus a few thousand dollars for six [in-person] ketamine treatments, it’s way less expensive than the hospital bill. Insurance companies have to see that this is saving them money in the long run.”

While there’s no way of knowing when things will shift in the coverage of ketamine treatment, organizations like the Ketamine Taskforce and corporate entities are actively doing the work.

Medicare as a path to coverage

To date, Ketamine Taskforce has applied to Medicare to prove that ketamine is an effective option for both depression and chronic pain. The treatment method for pain is similar to depression. It’s administered through an IV but for a longer period of time —about four hours— and at a higher dosage.

The task force was told that they need two separate applications for each condition, so over the course of six months, they focused on the application for coverage of ketamine therapy for pain.

“Most practices are charging about $1200 to $1500 for pain infusion because they’re done over four hours,” explains Juroviesky. “That’s prohibitively expensive for most people.”

If Medicare approves the task force’s application for coverage of ketamine treatment for pain, it will be on the National Coverage Determination, and insurance companies can no longer consider it experimental. If this step goes through, then the application for ketamine treatment for mental health is expected to pass as well.

“We’re hoping it will be easier to approve because Spravato has already been approved,” Juroviesky says. “It gives them proof that they’re already paying for this, and it came from ketamine, which is technically the same [compound].”

Additional steps are needed

The second hurdle for the Ketamine Taskforce is to get the American Medical Association (AMA) to create a Current Procedural Terminology (CPT) code, which can be used to get reimbursement for treatments.

“Unfortunately right now there’s nothing on the books to be a code,” Juroviesky says.

Before the code goes to committee, they send it to medical organizations, societies and associations they think will use the code. She says that when they submitted an application to the AMA to get a code, they were declined by some of the organizations they assumed would support them.

“We haven’t figured it out, but that’s on pause,” she says. “Once we get approved by Medicare we will resubmit to the AMAs and show them that it was approved by Medicare.”

We’re Hopeful For A Positive Future

Currently there isn’t a confirmed timeline for when ketamine therapy will be a commonplace treatment that is covered by insurance plans, but we are confident that there will be a shift in the right direction in the future. We will continue to make efforts to push for real change and will continue to successfully treat as many patients as possible. If you are interested in learning more, please feel free to contact us with any questions.

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