How Health Insurance Coverage Works for Addiction Treatment

How Health Insurance Coverage Works for Addiction Treatment
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Most health insurance plans offer addiction and mental illness treatment coverage. It’s more than likely that your health insurance plan covers treatment for addiction and mental health disorders, however the extent to which treatments are covered are dependant on individual health insurance policies. Insurance options provided for substance abuse treatment and treatment for mental illness are now extensive, but it takes some knowledge of insurance processes in order to navigate getting help for an addiction.

For an exceptionally long time, substance abuse and mental illness was not seen as worthy of coverage by many health insurance companies. Only in the most recent years has this began to change. 

The notion that addictions, mental illnesses, and other mental and behavioral health problems were less severe and thus less deserving of insurance coverage was challenged after the passing of the Mental Health Parity and Addiction Equity Act, or “MHPAEA”. This act, according to cms.gov, made it unlawful to “[impose] less favorable benefit limitations on those [mental health] benefits than on medical/surgical benefits.” Insurance companies could no longer devalue mental illnesses and addictions nor discriminate against them in terms of the treatment they decided to cover while treating them.

Treatment facilities have seen an influx of insurance coverage in the United States for addiction treatment. This is also partially due to the Affordable Care Act (often referred to as the ACA or “Obamacare”).

The Affordable Care Act

The Affordable Care Act , put in place in 2010, has made health insurance coverage for rehab centers much more accessible to every individual in the United States- no matter their financial status. The aim of the ACA was to grant healthcare coverage to those who did not have the luxury of acquiring and maintaining a health insurance plan along with all of its notorious costs.

Of course, this is great news- more people are covered in the United States than ever before. According to census.gov, 91% of people had health insurance 2017. But what type of addiction treatment exactly is available to those who have health insurance?

There are multiple levels of treatment in addiction rehab centers and mental illness facilities. Some of the levels of care that are usually covered by insurance plans include:

  • Medical detoxification services, including every necessary medication
  • Residential or inpatient care at a reputable facility
  • Multiple types of outpatient care
  • Individual therapy sessions
  • Maintenance addiction medicine for medications (such as Naltrexone)

Verification Of Benefits And Medical Necessity

Allowing your provider to verify your insurance benefits will allow you to see what your plan covers. In order for someone to be covered by their insurance company at a rehab center, the provider must first verify their insurance benefits and then continually prove that it is medically necessary for someone to be seeking help at a trustworthy program.

Each health insurance company and insurance plan has specific benefits, regulations, and stipulations. Insurance plans vary individually in their deductible amounts and coinsurance rates. However, this agreement is a contract that a member makes with their health insurance company at the time of their enrollment. 

Even if your addiction treatment is covered and your provider’s services are verified by your insurance company, it doesn’t necessarily mean you won’t have to pay any out-of-pocket costs.

Preferred Provider Organizations

Preferred Provider Organizations, commonly referred to as “PPO” plans, are insurance plans in which a member gets more freedom to choose their specific providers, whether they are specialists or any other type of doctor. The drawback, of course, is that these plans cost more money. On the contrary, a Health Maintenance Organization, or HMO, affords less freedom when it comes to choosing providers and healthcare facilities. Nonetheless, these plans cost the member less and often make choosing doctors less overwhelming and confusing.

Choosing an in-network provider makes finding a rehab center a bit easier while also making financial coverage for mental health services a bit more easy to obtain. An insurance company may reimburse you for the services administered at an out-of-network rehab, but this could require out-of-pocket costs up front.

What Types Of Drug Addictions And Mental Illnesses Are Covered?

Fortunately, most drug addictions are treated and covered equally in the arena of insurance. For example, alcohol addictions generally will be taken as seriously as heroin addictions – and financial reimbursement tends to reflect this concept. This idea pertains to treatment for mental illnesses and disorders as well.

Laws on addiction and mental health coverage don’t state the need for explicit differences in coverage for different types of addictions, nor for different types of mental illnesses. Distinguishment between the varying types of conditions within each category is overall unnecessary as a whole, case-dependent; mostly all are as threatening to the life of the member as the next.

Maintenance Programs

Maintenance programs, a type of addiction treatment mentioned above, are specifically built for those who cannot reach an appropriate level of functioning in society in the absence of drugs alone – even after rehab and other means of addiction treatment. It isn’t entirely uncommon for insurance companies to cover maintenance programs. It does, however, involve a process of proving thoroughly that these services are medically necessary and vital for the member’s health.

Certain addictions, like heroin or meth addictions, are more likely to provoke coverage for maintenance programs from insurance companies. 

Get Covered For Addiction And Mental Health Treatment

If you or a loved one needs rehab for a drug addiction or substance abuse disorder, or treatment for a mental health disorder, it’s best to start by talking to your healthcare plan administrator. Health insurance plans can be tricky to navigate alone, and it’s important that you get the most out of the plan you chose so that abetter quality of life can be achieved.

Addictions help kill 2.8 million people a year in the entire world, according to Webmd. According to the American Foundation for Suicide Prevention, in 2017, 47,173 Americans died from suicide. Addictions and mental illnesses are as dangerous, important, and serious as any other medical issue that insurance companies contribute coverage for. Get the most out of your insurance plan. Their


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