Under federal law, most private insurance plans and all government insurance plans must provide coverage for addiction rehab. But that doesn’t necessarily mean every treatment program will be covered under your plan or that your healthcare plan will pick up the tab for treatment 100%. Here’s what you need to know to find out whether your insurance pays for rehab.

Understanding Behavioral Health and Addiction Coverage

Under the Affordable Care Act, health insurance policies sold through the marketplaces, along with Medicare and Medicaid, must all provide benefits for behavioral health care, which includes addiction treatment. That means if you have any of those types of insurance plans, you have some type of coverage that will help pay for these services.

Previous federal laws also require parity with behavioral health coverage. That means that if an insurance policy includes this type of coverage, it can’t come with excessive deductibles or copays that other coverage under the policy doesn’t come with. For example, if your medical care deductible is $2,000, the health coverage company can’t impose a separate and much larger $10,000 deductible on behavioral healthcare services to try to discourage you from using them.

If you have coverage for substance abuse services under your healthcare plan, the total amount insurance will cover depends on a number of factors. Some of the biggest factors are explained below.

In and Out of Network

Many healthcare plans operate on network systems. They require providers — the people and facilities that provide services — to apply to be in-network with them. When you are treated by an in-network provider, the insurer foots more of the bill than when you are treated by an out-of-network provider.

For example, a plan might indicate that copays are 20% for in-network treatments and 40% for out-of-network treatments. So, if drug abuse services cost a total of $10,000 and you get them through an in-network provider, the insurance will only put $2,000 to patient responsibility. That’s the part you, the patient, end up owing. If you got the same services through an out-of-network provider, the total patient responsibility would be $4,000.

This is just an example, but you can see why it’s important to understand whether there are in- and out-of-network provisions under your policy. If so, you may want to work with a rehabilitation facility that’s part of that network to ensure your policy covers as much of the cost as possible.

Deductibles, Copays and Coinsurance Amounts

Other factors that determine how much your policy helps pay for drug rehab — and how much you may need to pay — are deductibles and copays. Most healthcare plans require you to share some of the cost of your care. That’s managed through these factors.

Your deductible is how much of your total care each year you have to pay for before your policy starts to cover things. Luckily, you probably only have one deductible. That means if you have used your health coverage for anything — from routine physicals to ER visits to a hospital stay — those charges have added up to count toward your deductible.

Here’s a scenario to help you understand:

  • Sue has a policy with a $3,000 deductible.
  • She has been to the ER once and paid $700 in services. She has had three doctors appointments for a total of $600 in charges, and she has $200 in medication charges. That’s a total of $1,500 toward her deductible.
  • She has $1,500 left on her deductible. If Sue seeks addiction recovery services, she would be responsible for the first $1,500 in charges before her policy started to pay on claims.

Copay and coinsurance amounts are the totals you pay for services after you meet your deductible. This is different for every plan. Some policies frame copays as percents, such as 10% of inpatient charges. Others set a specific number, such as $500 for each stay.

Preauthorizations and Referrals

Depending on your healthcare plan, a preauthorization or referral — or both — may be required to ensure the insurer will pay claims for services.

A referral occurs when your primary care physician provides a referral for you to seek other services. This can occur in several ways. Sometimes the physician writes a prescription for the other services. Other times, they may simply call ahead to the facility to arrange an appointment so you can seek a consultation for addiction treatment. In these cases, the physician’s office and rehab center work together to ensure the referral is documented appropriately.

A preauthorization occurs when the treatment center gets approval from the insurer to provide services before you enter an addiction treatment program. If your provider requires a preauth, this step is necessary. Otherwise, your provider may deny any claims for services provided.

The Importance of Insurance Verification

“Does insurance cover rehab?” is actually a complex question, as you can see from the information above. But professional drug treatment centers are used to dealing with these details, and they can help you navigate policy issues.

In fact, most providers, including Changing Tides, know that conducting an insurance verification is a critical first step when someone is seeking substance abuse programs for addiction. A verification involves a provider calling your carrier to verify:

  • That your coverage is currently in effect
  • That the provider is able to bill for services under your plan
  • Whether or not the provider is in-network
  • What your deductible and copay amounts are
  • Whether a preauth or referral is needed

By understanding the answers to all these questions, Changing Tides is able to provide you with information that includes an estimate on how much you may owe for drug abuse treatment if you go through a program with us.

Does My Health Coverage Pay for Treatment at Changing Tides?

Changing Tides Recovery Center is proud to accept numerous healthcare providers, including Cigna, Aetna, United Healthcare and some Anthem BlueCross plans. To find out whether your insurance will pay for rehab services at our addiction treatment center in North Carolina, fill out our contact form or call 252-715-3905 now!

We’ll get your policy information and conduct a verification. And if our program is not a good fit for your healthcare policy or substance abuse treatment needs, we’ll work with you to provide some recommendations for other programs. 

Changing Tides accepts most major insurance policies including those from Aetna, Anthem BlueCross BlueShield, Cigna, and United Healthcare