Does Insurance Cover Rehab Treatment?

When choosing insurance, you have two main choices: private and public. Both can help pay for addiction treatment, but the level of coverage you get can differ.

Private Insurance

This includes the health plans you might get through your job (group plans) or buy independently (individual plans). Whether you’re obtaining health insurance through your employer or buying it independently, it’s important to understand that addiction treatment is classified as an essential health benefit under the Affordable Care Act (ACA). This means that private insurers cannot simply refuse coverage for treatment of substance use disorders.

If your employer offers a group plan with more than 50 employees, they cover your treatment. This is under the Mental Health Parity and Addiction Equity Act of 2008. This law ensures that mental health and addiction treatment receive the same attention as other medical care. You will have the same coverage for these services as you do for any other health issue.

Nonetheless, the extent of coverage you receive can differ based on your plan. Therefore, although they must assist, the precise specifics will hinge on what your particular plan includes.

There are a few different types of private plans:

• PPO (Preferred Provider Organization):

This kind of health plan covers you when you use healthcare providers and facilities that are part of a selected group. A PPO, or Preferred Provider Organization, gets its name because the insurance company has made deals for lower rates. These rates are with a selected group of “preferred” providers.

These are the healthcare providers and medical facilities that constitute the network or in-network choices. The idea is simple: when plan members use these preferred providers, the providers can treat more patients. This helps them offer lower, discounted rates. It’s beneficial for both parties.

If you choose a healthcare provider outside your network, you’ll pay more than if you pick one inside your network. Some plans may cost more for certain services. Some services might not receive any coverage or may only receive partial coverage.

• HMO (Health Maintenance Organization):

These tend to be more restrictive, usually sticking to in-network providers only. If you want a rehab center under this plan, make sure it is in the network. This will help you avoid extra charges.

If you work for a company with at least 50 employees, check your employee handbook. Look for information about coverage details. If you visit a provider outside the HMO’s network, called an out-of-network provider, your plan may not cover the appointment. This usually happens unless it is an emergency.

With the ACA, addiction treatment has to be covered just like any other medical care, no less. PPOs and HMOs give you access to a variety of services, such as:

• Addiction evaluations and detox programs
• Alcohol and drug testing
• Brief interventions
• Visits to clinics
• Home health visits by recovery specialists
• Medication for addiction treatment
• Behavioral talk therapy sessions (Most likely evidence-based therapies)
• Anti-craving medications
• Outpatient treatment
• Inpatient care
• Aftercare planning, community support programs, and other recovery classes

Remember that most insurance plans want you to stick with in-network providers to get the full benefits.

Public Insurance

Public insurance programs, such as Medicaid and Medicare, do cover rehab services. However, your eligibility can depend on a few things—like your income, age, and other personal factors. It’s essential to check the specific requirements for each program to see if you qualify.

• Medicaid: Medicaid is a program that helps people based on their income. It gets its funding from the federal government. However, each state runs it a bit differently. This means that the rules for who qualifies and what is covered can change significantly based on your location.
• Medicare: Medicare is a federal health insurance program. It is for people who get Social Security benefits. It is also for those who are 65 or older or have a permanent disability.

People who get railroad retirement benefits or have end-stage kidney disease can also qualify for Medicare. Medicare covers treatment for alcohol use disorder and other substance use disorders under certain conditions:

• The provider must state that the services are medically necessary.
• You must receive care at a facility that is both in-network and approved by Medicare.
• Your provider is responsible for setting up your care plan.

Before you begin treatment, check if the mental health or substance abuse center accepts Medicare or Medicaid. Not all do, so it’s essential to verify this with the facility first. You don’t want to run into any surprises down the road.

The level of coverage for drug and alcohol rehab costs will vary based on your insurance plan. Regrettably, some health insurance providers cover a fraction of the overall rehabilitation expenses. Private insurance plans are the most expensive option.

However, they offer many choices. This lets you pick the treatment service that fits your needs. If you do not have private insurance or your plan does not cover alcohol and drug treatment, public insurance plans are the best option.

The factors that can influence the extent of insurance coverage for your drug and alcohol rehab include:

• Policy Type: The type of insurance policy you have—private, Medicaid, or Medicare—will determine your addiction treatment coverage. Each one offers different levels of protection. Please study your policy carefully to understand what it covers.
• Location of the Treatment Facility: Rehabilitation centers in expensive, well-known city areas charge more for their services. This is compared to centers in less developed, rural areas. The presence of specialized services and the standard of the local healthcare system can also affect the overall expense.
• Treatment Provider: Your insurance might ask you to pick an in-network treatment center. If you go with an out-of-network one, be prepared to pay more out-of-pocket. It’s always a good idea to check which facilities are covered to avoid unexpected costs down the road.
• Level of Care and Type of Facility: Outpatient programs let you go home after your therapy sessions. This makes them a cheaper option than inpatient facilities, where you stay on-site for the whole treatment. In comparison, standard facilities provide care at a more affordable price. Conversely, luxury accommodations offer premium care with tailored services, yet they carry a significantly steeper cost.
• Amenities Provided: A luxury rehab center has special features. These include a gym, nutrition coaching, and a swimming pool. Because of these amenities, it will probably cost more than a basic rehab center.
• Length of Stay:  When rehab stays stretch out, the costs go up. This happens because patients need more care and support from the medical team. But, for some, the extra time can pay off. A more extended stay might give them the chance to receive more detailed treatment and improve their chances of a full recovery.
• State Regulations: Insurance coverage for addiction treatment varies from state to state. Some states require more extensive coverage, while others have more limited requirements.
• Personal Factors: The patient’s condition can affect the costs of alcohol rehabilitation. Factors include the severity of their addiction, any other health issues, and their specific treatment needs. Individuals with more complex problems may require additional resources and specialized treatment. In that circumstance, the rehabilitation expenses rise.