Ambetter is a Health Insurance Marketplace company, which means that it provides health insurance options for families, small business owners, and others through the government-run service.
Ambetter has been with the Marketplace since 2013 when it began and has 3 million members with health insurance plans in 27 states.
Ambetter states that it believes in fostering growth through local communities. Its employees live locally and partner with local organizations to support their communities.
Does Ambetter Cover Rehab?
As a Health Insurance Marketplace provider, Ambetter covers drug and alcohol addiction treatment under the umbrella of essential health benefits.
This coverage extends to all levels of care and severity of substance use disorders. You can find coverage for inpatient treatment and outpatient treatment under Ambetter.
You can also find covered services for opioid use disorder, alcohol abuse, stimulant use disorder, and other forms of substance abuse.
Ambetter works with the Cenpatico Behavioral Health Network, which relies on the American Society of Addictive Medicine (ASAM) criteria.
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Substance Abuse Treatment Services Covered By Ambetter
Understanding coverage for a variety of levels of care can be overwhelming. Take a look at the table below for a breakdown of service settings and coverage.
|Treatment Type||Covered||Not Covered|
|Partial Hospitalization Program||✔️|
|Intensive Outpatient Program||✔️|
Ambetter Coverage By Treatment Type
Ambetter has three basic categories for addiction treatment, and all treatment types fit into one of those categories.
The three categories are:
The intermediate category is the broadest and includes:
- medical detox
- in-home services
- residential treatment
- partial hospitalization (PHP) and intensive outpatient programs (IOP)
Look through the tabs below for more information about each treatment type.
Ambetter Plan Types
Ambetter offers three main levels of insurance plans. These levels are organized according to premium cost versus out-of-pocket costs.
The three main plan types are:
- Ambetter Bronze Care, which has low monthly premiums but higher out-of-pocket costs
- Ambetter Silver Care, which has a balance between premiums and out-of-pocket costs
- Ambetter Gold Care, which has high premiums but lower out-of-pocket costs
Ambetter also offers some value insurance plans in select states. These include lower costs as long as treatment is through a select provider or a telehealth option.
How To Use Ambetter Coverage For Substance Abuse Treatment
Ambetter works with the Cenpatico Behavioral Health Network to offer addiction treatment providers in many states.
You can choose from available providers by searching your zip code on Cenpatico’s website.
With Ambetter insurance coverage, you do not need a treatment referral for addiction recovery services. However, you may need prior authorization for certain treatment options.
Services that require prior authorization include:
- inpatient treatment
Ambetter Co-Pays And Deductibles For Addiction Treatment
Ambetter offers different deductibles, co-pays, and coinsurance costs depending on which insurance plan you have.
Your basic deductible for the Bronze plan is $1,500 for an individual and $3,000 for the family.
Addiction treatment services are divided into inpatient and outpatient categories. Outpatient treatment requires a $40 co-pay for an office visit and 50% coinsurance for all other services.
Inpatient treatment requires a $3,000 co-pay per day.
The Silver plan balances premium costs and out-of-pocket costs. The Silver plan’s basic deductible is $4,750 per person and $9,500 per family. (These respective numbers are doubled for out-of-network providers.)
For outpatient substance abuse treatment, you would owe a $45 co-pay per visit or a $22.50 co-pay per group therapy session.
For inpatient care, you would owe 30% coinsurance for both the costs issued by the facility and by the physician.
If you have a Gold plan, you do not have a deductible.
For outpatient substance abuse treatment, you would owe a $35 co-pay per visit and a $17.50 co-pay per group visit.
For inpatient services, you would owe a $350 co-pay per day. People insured under the Gold plan have a cap on out-of-pocket expenses, which is $8,550 for an individual and $17,100 for a family.
What Addictions Does Ambetter Cover?
Ambetter has no restrictions on the forms of substance abuse that it covers.
Covered substance use disorders include:
- opioid use disorder
- stimulant use disorder
- alcohol use disorder
- cannabis use disorder
- addiction to psychedelics or party drugs
What If My Insurance Plan Doesn’t Cover The Treatment Program I Need?
If you do not have coverage for the treatment program that you need, or if you have inadequate coverage, this can pose a major barrier to care.
Fortunately, there are other avenues for financial help that you can consider.
The Substance Abuse and Mental Health Services Administration (SAMHSA) provides block grants to all 50 states, which then distribute them to qualifying rehab centers.
Each drug rehab center then passes the savings on to the client. Treatment centers can also apply for drug- or treatment-specific grants to make treatment more affordable for clients.
Even if you have private insurance, you should consider applying for Medicaid or other government-funded insurance programs.
If you meet income, age, or other eligibility requirements, you may be able to get secondary insurance that covers whatever treatment cost that is not picked up by your current insurance.
Medicaid is intended for people with limited resources, and many rehab centers that accept this form of public insurance can help potential clients determine their eligibility and apply.
Payment Assistance From The Rehab Center
Rehab centers often provide payment assistance options.
These options may include:
- payment plans
- sliding fee scale
Finding A Rehab Center That Accepts Ambetter
There are a couple of ways to find a rehab center that accepts Ambetter.
If you already have rehab centers that you are interested in, call to ask if they accept Ambetter. Even if they are out of network, they may be willing to work with Ambetter.
You can also go to Cenpatico’s website and search for in-network addiction treatment centers close to your zip code.
If you are still having trouble, you could call the Ambetter customer service line and ask for help.
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Updated on October 31, 2023
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- Ambetter Health - About Our Plans
- Ambetter Health - Essential Health Benefits
- Ambetter Health - Member Handbook
- Ambetter Health - Select Your State
- Ambetter Health - What is Ambetter Health?
- Ambetter Summary of Benefits - Bronze Plan
- Ambetter Summary of Benefits - Gold Plan
- Ambetter Summary of Benefits - Silver Plan