How Insurance Pays for Addiction Treatment

You shouldn’t have to worry about how to pay for addiction treatment.

handsome senior man with glasses on the phone in his office - insurance

Fortunately, many insurance companies recognize substance use disorder as a legitimate healthcare issue and provide some form of coverage for its treatment.

You or a loved one should review your policy carefully and arrange for a consultation with your insurance carrier so you have all the facts. Then, if you’re in Arizona, you can talk with a Cottonwood Tucson admissions counselor about specific medical and therapeutic needs, and what your insurance coverage allows for in-state treatment. If you’re considering traveling for out-of-state care, you’ll need to confirm that this option is available under your existing policy.

What the Law Requires

If you’re suffering from drug or alcohol addiction and want rehabilitative treatment, the Affordable Care Act (ACA), the American With Disabilities Act, and the Mental Health Parity and Addiction Equity Act (MHPAEA) provide protection. In 2008, MHPAEA was expanded to require “health insurers and group health plans to provide the same level of benefits for mental and/or substance use treatment and services that they do for medical/surgical care.” This includes qualified plans found within the Health Insurance Marketplace, or HealthCare.gov.

However, an important caveat to insurance paying for substance abuse treatment is you’re not protected by these acts while currently using drugs or alcohol. So, the timeframe is short between making a decision to seek help and using insurance benefits for treatment.

What to Discuss With Your Insurance Provider

Your fact-finding mission starts with a couple of steps. If you’re not able to fully comprehend the complexities of some of these details, ask a trusted family member or friend for help.

Review the Summary of Benefits and Coverage (SBC)

This standardized document, implemented under the ACA, requires insurers to provide an SBC for each plan. Each insurance company uses this sample format to help explain the features and benefits of a specific plan.

Under the “Common Medical Event” category, the SBC for your plan should have an entry for “If you need mental health, behavioral health, or substance abuse services.” Then, it will detail services, network and out-of-network costs, and relatable limitations and exceptions. Simply request a copy of your plan’s SBC, as well as a copy of the uniform glossary that explains the terms used in the SBC. You might also find this information online under your provider’s plan breakouts.

Talk to a Customer Service Representative

Once you have your SBC and glossary of terms, contact your plan’s member services department, and discuss some of the following insurance cost factors for inpatient and outpatient rehabilitation:

  • Addiction treatment medications: Some continuum of care plans require the use of medications for a gradual withdrawal from certain substances or to manage co-occurring disorders.
  • Alcohol and drug testing: This might initially be required as part of an employer’s mandate when you return to work, or a stipulation of extended outpatient services.
  • Ancillary treatments: Certain facilities provide residents with wellness services such as acupuncture, or special amenities that include excursions and activities. To prepare for out-of-pocket expenses, confirm what your treatment coverage allows.
  • Anti-craving medications: Certain treatment options may require you or a loved one to stabilize recovery with the use of these prescriptions.
  • Assessment by a physician or the addiction treatment facility: Typically, this assessment is required before an insurance carrier authorizes treatment, but the type of pre-admission assessment may need clarification.
  • Clinic visits: Some providers mandate these initially, periodically, or as part of ongoing treatment.
  • Detoxification: Medically-assisted detoxification might not be necessary, but you should still confirm what procedures are covered.
  • Home health visits: Your attending specialists may recommend these for individual cases or within the structure of extended outpatient services.
  • Family counseling: Many rehabilitation centers include this component for whole health wellness, but that doesn’t mean your policy includes it.
  • Inpatient (residential) treatment: An assessment may reveal that inpatient rehabilitation is best for you or a loved one, so you’ll need to clarify coverage for the duration of your stay, such as 30, 60, or 90 days.
  • Mental and behavioral health assessment and treatment: Additional diagnostic care might be required for process addictions, co-occurring disorders, mood disorders, and trauma recovery.
  • Outpatient treatment: Some insurance coverage may only extend to inpatient or outpatient care, both, or neither.

Your Plan and Treatment Options

Before you decide on a treatment center, have a clear understanding of the full costs and benefits of the facility. Then, compare them to your policy and confirm:

  • Out-of-network and in-network coverage.
  • Scaled payment options after the deductible is met.
  • Guidelines regarding frequency of admittance, aftercare programs, or treatment modifications after relapse.
  • If flexible spending dollars can be used for treatment.

What Happens If My Insurance Doesn’t Cover Treatment?

This is a valid concern for some people. MHPAEA also provides a connection to resources if you were denied coverage, reached your plan’s limit, or can’t afford your deductible or co-pay. Its website provides a checklist to direct you to state and federal agencies that might provide assistance.

Also keep in mind that most rehabilitation facilities, such as Cottonwood Tucson, provide financing and private pay options. You shouldn’t be without the care you need.

For more information about Cottonwood Tucson, Arizona addiction treatment center, call (800) 877-4520. We are ready to help you or your loved one find lasting recovery.

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