Insurance Coverage For Drug And Alcohol Addiction Treatment

With private rehab centers averaging a cost of $1,000 per day, insurance is a key component in determining what rehab center yourself or a loved one would attend. Whether you have a ppo, hmo, state insurance (medicaid, medicare), or no insurance, there are options available for you. Private insurance companiees (PPO’s, HMO’s) may cover up to one hundred percent of your stay at a drug and alcohol rehab center.

Using Insurance To Pay For Drug Rehab

Paying for addiction treatment can be a major stressor for many people. To start, insurance coverage for addiction treatment has only recently become mainstream. In previous years, health insurance was largely a luxury, and addiction treatment could only be sought by the more fortunate citizens.

Now, however, the majority of American citizens have health insurance, due largely to the Affordable Care Act. In addition, the 2008 Mental Health Parity and Addiction Equity Act ensured that insurance carriers must provide coverage for addiction and mental health issues to the same extent they do other medical conditions.

All in all, paying for addiction treatment is easiest when a person has a great health insurance plan. If a person already has a plan, the next step is to find out the exact benefits and what’s covered. People who do not have insurance plans also have hope—insurance companies cannot discriminate against persons with pre-existing health conditions, including addiction and mental disorders.

How Does Health Insurance Work For Addiction Treatment?

To use health insurance for addiction treatment, patients first need to know a few key factors about their individual plan: whether they must complete a precertification, what is their deductible amount, and any copays they’ll be responsible for paying. Anyone who wants to find this information can easily do so by contacting their provider or a treatment specialist.

Pre-certification/Prior Authorization

Many health insurance plans require policyholders to obtain a prior authorization from the provider before entering a treatment program. This ensures that clients are only receiving treatment they actually need and that the insurance provider will pay for the services.

Prior authorization, also called precertification, means a person will be required to obtain an official diagnosis which shows “medical necessity” for treatment. This simply means that a person must see a primary care physician or treatment specialist for a full clinical assessment to show that addiction is present and that the person is in need of treatment.

In some cases, insurance companies will require a person attend outpatient treatment before entering an inpatient addiction treatment program, so it’s necessary to know what will be covered by a person’s specific plan.

Deductibles

The insurance deductible is the amount a person must pay toward health expenses before an insurance plan will cover services. Deductible requirements are very specific, so knowing the exact parameters of a person’s plan before selecting a treatment program is necessary to avoid excess costs.

Copays

Most insurance programs will come with a copay system for many services. This means the policyholder is responsible for a certain amount or percentage of treatment costs and the insurance plan will cover the rest. For many inpatient drug rehab programs, policies cover up to 80 percent of treatment stays, but this number varies by individual plan.

The rate at which insurance carriers cover addiction treatment is also affected by other factors, such as whether a person needs a medical detoxification program and the length of stay needed.

Insurance Carriers Commonly Accepted By Drug Rehab Centers

Because so many insurance providers now offer coverage for inpatient addiction treatment, most addiction treatment centers accept plans from major, private insurance carriers. The following private insurance carriers are commonly accepted by drug and alcohol rehab centers throughout the United States:

  • Aetna
  • AmerigroupAmeriHealth
  • Anthem
  • Assurant Health
  • Beacon Insurance
  • Blue Cross Blue Shield
  • COBRA
  • Cigna
  • Health Alliance
  • Humana Health
  • Kaiser Permanente
  • Medical Mutual
  • Obamacare (The Affordable Care Act)
  • Tri-Care
  • United Healthcare

What’s Covered By Insurance For Addiction Treatment?

The exact services covered by an insurance plan will depend on whether the plan covers inpatient treatment, outpatient treatment, or both types. Many insurance providers now recognize that, for people with severe addiction issues, inpatient treatment is the most comprehensive and effective form of care, and often provide coverage for it. However, some plans still only cover outpatient programs, or at least require patients to first attend outpatient treatment before moving on to inpatient.

The type of treatment a person needs will often be determined during an initial clinical assessment through a doctor or treatment specialist prior to treatment. When a person enters a drug rehab program, the first course of action is to determine an individualized program, complete with a course for the duration of treatment. This program will incorporate various therapies and treatments that best fit the individual’s needs.

Which treatments are offered will vary by facility, and which treatments are covered will vary by insurance plan and individual need for treatment. For example, a person with a physical dependence will likely need medication-assisted treatment and/or a medical detox. When deemed medically necessary, it’s more likely the insurance plan will cover this service if it provides coverage for it.

Medication coverage for addiction treatment will also be determined by individual plan and patient need. People with severe opioid or alcohol dependencies will enjoy a greater treatment outcome when pairing traditional treatments with medication-assisted therapy, so medication can play a big role in recovery. It’s always best to figure out exactly which treatments, program types, and medications will be covered before entering treatment.

Drug Addictions Covered By Health Insurance

Addiction is one of the 10 essential health benefits which must be covered by insurance providers participating in the insurance Marketplace, and the majority of private insurance carriers also adhere to this standard of care.

Addiction is a disease which affects both the body and mind regardless of the drug of abuse, and insurance providers cover treatment for it usually without excluding certain drugs. Treatment for most drug and alcohol addictions will be covered by your insurance plan if coverage for addiction care is already provided by that plan.

Still, anyone who is unsure if treatment for the drug they’re addicted to is covered by their plan can access a summary of benefits and therapies page, required for all insurance plans by the U.S. Department of Health and Human Services.

Mental Health Disorders Covered By Health Insurance

As with addiction, insurance plans tend not to discriminate against mental health care coverage for certain disorders. A person with bipolar disorder and addiction should be able to receive the same level of coverage as a person with generalized anxiety disorder and addiction, according to federal regulations for insurance providers. To know for sure, a person can speak to a benefits administrator, contact their insurance provider, or call a treatment specialist.

Understanding Your Health Insurance Plan

To understand the benefits provided by your insurance plan, it may first be helpful to know which type of plan you have. Most health insurance plans fall into one of three categories: private, public, or group insurance plans.

Private Insurance Plans

Private insurance plans are those a person seeks independently or through an employer. People with private insurance plans often pay higher monthly premiums, but these plans often provide the highest level of coverage.

Private plans are typically classified as either HMO, PPO, or Point-of-Service plans.

  • HMO (Health Maintenance Organization): HMO plans operate within a specific network of treatment providers and usually do not cover care outside of the network. If a person has an HMO plan and seeks treatment at a drug rehab center outside the network, they’ll likely have to pay for most or all treatment costs.
  • PPO (Preferred Provider Organization): Similar to HMO plans, but often pay a higher percentage for out-of-network care and may offer a wider range of in-network treatment providers.
  • Point-of-Service: Often viewed as the most beneficial type of health plan, Point-of-Service plans allow individuals to choose between HMO and PPO services for each type of treatment.

Public Insurance Plans

People who do not have private insurance plans may qualify for public insurance plans, or those funded by local or federal governments. Public insurance plans include Medicaid and Medicare and have specific guidelines for qualifications.

Medicare insurance plans are only available to eligible applicants ages 65 and older and those who have End-Stage Renal Disease (ESRD). Medicaid insurance plans are available to those who meet income and/or disability qualifications.

Group Insurance Plans

Group insurance plans are a form of private plans available to members of a particular group, such as member associations or private employers. Group plans may offer a higher level of coverage at a reduced cost and often fall under similar guidelines as private plans.

What Isn’t Covered By Insurance For Addiction Treatment?

There are many health insurance regulations now in place to ensure that people receive the treatment they need without discrimination against their need for that treatment. In other words, a person with a chronic illness, such as diabetes, will not receive a higher level of coverage than a person with the chronic illness of addiction.

However, as with treatment for other conditions, guidelines for addiction treatment are specific, both according to the plan and the provider. In addition to figuring out what precertification requirements a person must meet prior to entering treatment, it’s also important to know exactly which treatment programs, types, and medications are covered.

Some questions to ask an insurance provider before entering addiction treatment include:

  • Does my plan cover inpatient addiction treatment? Outpatient treatment?
  • Will my plan pay for medication during withdrawal? Medication management?
  • Will my plan only cover 12-step-based programs, without medication?
  • Does my plan have coverage for any forms of aftercare, such as outpatient programs?
  • What is my daily copay for an inpatient treatment stay?
  • Will my plan only cover a certain length of inpatient program, such as 30 days?
  • Does my plan require that I enter treatment for a minimum length of time, such as 90 days?

Seeking Addiction Treatment With Your Insurance Plan

Having an insurance plan can mean the difference between a person being able to afford the care they need and choosing not to go due to treatment costs. The most important choice a person may ever make is entering a treatment program which will help them become sober, learn the skills they need to manage their addiction, and enter recovery equipped to lead a fulfilling, substance-free life.

Treatment can begin as soon as a person learns what’s covered for addiction treatment by their insurance plan and selects a rehab program. Learn more about insurance coverage for addiction treatment by contacting a treatment specialist today.

This page does not provide medical advice. See more
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