- Content Reviewed By:
- Andrew McKenna - JD
- Deputy Director of NCADD Westchester
How Do I Know My Insurance Will Cover My Drug Rehab and Treatment?
Drug addiction is a complex chronic medical disease that requires expert care from experienced and qualified medical and behavioral health experts. It’s subject to the same insurance coverage protections as conditions, like diabetes, heart failure and hypertension. In recent years, landmark legislation has significantly strengthened insurance coverage options for addiction and substance use disorder. The Affordable Care Act has listed substance abuse and behavioral health as an Essential Health Benefit. This means that private plans offered on the ACA Marketplace must offer at least some component of behavioral health coverage.
Additionally, the Mental Health Parity and Addiction Equity Act (MHPEEA) prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. Even private insurance plans outside of the ACA Marketplace purview, such as through your employer or other sources, offer increasingly robust insurance options for people struggling with some type of substance use disorder and/or mental health issue.
What Types of Insurance Plans Cover Drug Rehab?
There are essentially four types of private health insurance, including:
- Health maintenance organizations (HMOs) – Pre-established network of care providers who agree to accept a set amount for each service provided.
- Preferred provider organizations (PPOs) – Although PPOs operate similarly to HMO’s, they allow you to choose any care provider you wish, whether they’re In our out of network. You may be responsible for the cost differential.
- Exclusive provider organizations (EPOs) – Restricts access to care to providers within your network but allows you to go straight to a specialist without seeing a primary care physician.
- Point-of-service (POS) plans – Lower costs for in-network providers and requires seeing a primary care physician for a referral before going to a specialist.
All of these types of insurance plans will pay for at least some level of behavioral health or drug rehab service, but your scope of coverage will depend on your plan tier.
Within these four types of insurance are the following tiers of coverage:
- Platinum Plan – Covers around 90 percent on average of your medical costs.
- Gold Plans – Offers around 80 percent coverage of your medical costs.
- Silver Plans – Covers around 70 on average of your medical costs.
- Bronze Plans – Covers 60 percent on average of your medical costs.
The best way to find exactly what your plan does or doesn’t cover is by speaking with a representative of your insurance company and getting a full breakdown of your benefits. Very few people fully understand their insurance policy until they need to seek care for a specific condition. There’s no shame in asking for clarification on the exact fabric of your plan. You have the right to a clear and transparent explanation of your benefits, and you shouldn’t have to jump through hoops to get clear answers on your plan details.
What Types of Drug Rehab and Treatment Does My Insurance Cover?
Private health insurance plans generally cover, at least partially, a broad range of substance use disorder issues, including:
- Detox and Withdrawal Management – Medically supervised care for stabilization and treatment of acute withdrawal symptoms.
- Outpatient and Intensive Outpatient Rehab – Daily programs that include group therapy, individualized counseling, case management services and supplemental behavioral therapies, depending on facility resources.
- Medication-Assisted Treatment – Customized and closely monitored treatment programs that allow the use of FDA-approved medications to treat opioid use disorder, like buprenorphine (Suboxone®), naltrexone (Vivitrol®) and methadone.
Many private insurance plans will cover inpatient or residential treatment (programs in which patients stay at their facility while getting care), but due to the cost difference between inpatient and outpatient, many plans will more readily cover the latter option. Higher-tier plans will cover residential rehab and may even offer partial coverage for luxury programs. Other factors that can determine coverage for residential drug rehab, include length of stay and types of treatment you receive.
Get An Insurance Verification from Your Prospective Drug Rehab Facility
The best way to find out what insurance the facility you’re considering takes is just by asking them. The first admissions-related step to getting drug rehab is having an experienced and qualified representative conduct a full and thorough insurance verification so you know exactly where you stand, what programs you’re eligible for and whether or not that facility can adequately treat your drug rehab needs. You shouldn’t have to let money or logistics get in the way of helping yourself or the person you care about who is suffering from drug addiction. Make the decision to get treatment first, and the rest will follow. There are plenty of treatment centers that will accept your insurance for drug rehab, and those who don’t may be able to offer other options. The most important thing is to get help today. Start treatment now.