So, you’ve How to Open an Addiction Treatment Center in Illinois and now you’ve got questions about insurance billing in the state. Billing in Illinois is complicated, but it doesn’t have to be a mystery. 

Today, we’ll go over some of the most common questions we get about billing for addiction treatment - whether that’s inpatient, residential, IOP or PHP -  in Illinois.

What are the Most Common Health Insurance Plans Addiction Treatment Centers Deal With in Illinois?

In 2019, the Illinois Governor’s office issued a report describing the market shares of each insurance company in Illinois. There’s a few great takeaways from this report which will help you get grounded in the playing field so you can understand the landscape of insurance in the state.

• Group Comprehensive insurance plans are the most popular type of plan in the state. They comprise 31% of all plans in Illinois.

• Put together, Title XVIII Medicare and Title XIX Medicaid insure nearly 50% of the population in Illinois.

• Individual Comprehensive insurance plans account for less than 10% of all plans issued in the state.

• Group Comprehensive plans paid a total of over 9 billion in direct claims in 2019. In contrast, Medicare and Medicaid claims, put together, amounted to over $15 billion. 

What Are the Most Popular Health Insurance Payers in Illinois for Addiction Treatment?

We can answer this question using the same Governor’s report from 2019. 

• The biggest provider of Group Comprehensive insurance in Illinois, by far, is Health Care Service Corporation, or HCSC. They command a full 75% of the group market share in Illinois. 

• Meridian dominates in the Medicaid category with 35%, while Sierra Health and Life Insurance is the leader in the Medicare category, with 32% of the market. 

Do Insurance Payers Need to Cover Addiction Treatment in Illinois? 

Yes. Illinois, like many other states, has parity laws in place to protect patients with SUD and guarantee that they receive medical treatment for their disease just as patients with diabetes or cancer do. 

These parity laws are emphasized on Get Covered Illinois: 

In Illinois, every insurer that offers individual or group health insurance coverage is required to provide coverage based on medical necessity for the treatment of a mental, emotional, nervous, or substance use disorder or condition.

There are several different acts and laws that make up what is referred to as “Parity Laws” in Illinois. For a time, “grandfathered plans” didn’t have to follow the same rules as other plans in regards to covering addiction treatment. That is no longer the case in Illinois. All types of insurance payers in Illinois must comply with parity laws now, including: 

• Large group plans 

• Small group plans 

• Individual plans 

• ACA Marketplace plans 

What are the Most Common CPT Codes Used in Illinois for Addiction Treatment Billing? 

By far, the most popular CPT codes in Illinois are H0001HF, H0004HF, and 96164HF.  H0001HV, H0004HF and 96164HV are common, too, because they are the codes used for addiction treatment at agencies that receive some amount of government funding. 

These codes cover alcohol and drug assessments (H0001F/H0001HV), one on one therapy (H0004HF), and group counseling (96164HF/96164HV).

How Do Surprise Billing Laws Affect Addiction Treatment Providers in Illinois? 

Illinois has so-called “Surprise Billing Laws” that addiction treatment providers in the state must be aware of. When patients have no choice but to seek an out-of-network provider, such as in the event of an emergency, then they must not be charged a “balance bill” or held responsible for the extra expense of OON care in Illinois. This includes copayment, coinsurance and deductible payments. It can be very difficult, however, to prove that admission to an out-of-network addiction treatment program is warranted under surprise billing laws. When you’re working with out-of-network patients, be sure to disclose all potential payments that may be due as a result of care at your organization in compliance with Illinois state law. 

Need More Help With Addiction Treatment Billing in Illinois? We’re Here for You.

Behave Health is committed to making it easier - and more profitable - to operate evidence-based, results-focused addiction treatment centers.

Our all-in-one app puts clinical, administration, staff, admissions, alumni, residents, treatment plans, billing, insurance authorizations and more - all at your fingertips.

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.

Need help with certification? Behave Health can also help direct you to the right resources for help with Licensing or Accreditation by either The Joint Commission or CARF. Mention to your product specialist that you’re interested in this service after you start your free trial!