Covering the cost of drug rehab is one of the primary concerns for most American families who are trying to find treatment for a loved one in active drug addiction.
For many, it is the single barrier to treatment — the one thing stopping them from moving forward and getting the help they need to heal.
What types of treatment do insurance policies cover? What can families expect as they aim to get coverage for a loved one living with addiction?
Learn more about how health insurance works when it comes to addiction treatment. See if your insurance covers you or your loved one’s addiction treatment, what services may or may not be covered, as well as other ins and outs of addiction treatment insurance coverage.
Every insurance policy is different. Look over the policy’s documents to determine exactly what you can demand with authority from your insurance company. Insurance documents are not always easy to understand, so call an insurance agent and have them assist you in deciphering the information if you need help.
Often, rehab facilities have individuals on staff who can also help you determine your coverage.
Federal law regarding health insurance coverage and the specific treatments that are required to be covered is constantly changing.
Since the Affordable Care Act was passed, hundreds of thousands of Americans who could not previously afford health insurance coverage were able to connect with a health insurance policy to cover their treatment needs.
Even though more American families have health insurance coverage than ever before, the interpretation of what constitutes effective treatment, and, therefore, what types of drug rehab services will be covered by any given insurance provider, varies widely.
In general, the law states that insurance providers should provide coverage for all drug addiction and mental health disorders as is medically necessary. It is the definition of the term “medically necessary” that makes the process complicated for many seeking recovery.
Yes. Every insurance provider will define the term “medically necessary” very differently, requiring different evidence or proof that a requested service is actually needed. It may be a relatively simple process to get basic services covered. If there is a need for more intensive services or long-term care, it may be more of an uphill climb to ensure that insurance will pay the cost.
The type of health insurance policy you have will significantly impact what treatment services you will be able to access through insurance and how much of the cost will be covered by your provider.
“Medically necessary” refers to any therapy or medical treatment that is deemed necessary to the care and treatment for a diagnosed disorder. For example, it is relatively easy to get coverage for antidepressant medications if depression is diagnosed, and if there is an acute cardiac issue requiring a stent, the tests demonstrate to insurance that surgery is needed. In these cases, there is a report or testing that is done that says those interventions are medically necessary.
In the case of addiction, it is not as simple. If you believe, for example, that you require inpatient drug rehab because you will relapse if you undergo outpatient treatment, an insurance company will want to know why you need more expensive treatment over something that will cost them less. Without that evidence, they may not approve the charge for the more intense level of treatment.
Currently, insurance companies do not accept a higher risk of relapse during outpatient treatment, as compared to inpatient treatment, as proof that more expensive residential care is a necessity.
Most insurance policies will cover the cost of weekly hour-long therapy sessions with a therapist that is within their network. They will not cover the cost of an expert in addiction treatment if they are out of network. They will also not pay for any therapies or interventions that are not proven to be medically necessary even if there are signs that they could be helpful in preventing future problems.
Medical detox is one of the easiest things to get covered by insurance because it is often identifiably necessary. The withdrawal symptoms that come automatically with the cessation of certain drugs of abuse indicate that there is an immediate need for medical supervision and, in some cases, medication.
Beyond medical detox, which may be covered on an inpatient or outpatient basis depending on the co-occurring mental and medical health issues, outpatient addiction treatment services are often relatively easy to get covered by insurance.
It is the least expensive treatment because it does not include the cost of room and board, and it also provides for a reassessment of need every 30 days. Often, the program provides a step-down process that begins with a more intensive treatment schedule and tapers down, month by month, until clients can sustain themselves in recovery with a few therapeutic check-ins per week.
Inpatient care that lasts 30 days is the standard despite also being the bare minimum of what experts deem to be effective. If the individual has not already undergone an outpatient treatment program or been unsuccessful in other combinations of outpatient treatment, then insurance will likely push back and require medical documentation of need.
Just as it is often necessary to prove that outpatient treatment will not be effective before coverage for short-term care is provided, it will also be necessary to prove that long-term care is needed, often month by month as it becomes clear that the individual needs more time in comprehensive addiction treatment.
Some level of aftercare services may be simple to cover if it is medically recommended. In most cases, a regular therapist will be approved by insurance as will the continuation of medication use that began during treatment.
Coverage for experiential treatment, alternative therapies, or holistic treatments like acupuncture will likely not be covered, or they will come with a steep copay even if they were effective during drug rehab.
In general, the diagnosis of addiction and the success of previous attempts at treatment determine whether treatment will be covered, not the specific substance of abuse. The only time this information comes into play is in determining what services will be approved for treatment. Addiction to certain substances results in coverage for different services.
For addiction to marijuana, it will likely be difficult to cover the cost of medical detox because the withdrawal symptoms mostly will be psychological in nature. Initially, outpatient treatment may be approved, but long-term care will require continued proof of medical need.
For people who struggle with alcohol addiction, detox from alcohol can be deadly. Inpatient medical detox is required, so it is a simple process to get coverage. Coverage for treatment following detox will likely be based on the findings of doctors who monitored the alcohol detox.
Though prescription drugs such as benzodiazepines, opioid pain relievers, and stimulant drugs are prescribed for legitimate medical needs, they can quickly become the source of a new and deadly problem.
Medical detox for benzodiazepine addiction, for example, will likely be covered if dependence is identified because withdrawal can be deadly if attempted without medical supervision. Though painkiller detox is not life-threatening, it is known to cause significant medical and psychological issues. Coverage for outpatient medications like methadone and buprenorphine is relatively simple to access.
In all cases, outpatient treatment will be recommended. Inpatient treatment will likely only be approved if there have been multiple failed attempts at outpatient treatment.
Cocaine and crystal meth are lethal drugs. They continue to be common drugs of choice among people seeking treatment for addiction. Unless there is a serious co-occurring mental health disorder, medical detox is rarely covered. Outpatient care will likely be covered, and inpatient treatment may need to be proven necessary.
Addiction to heroin, despite the significant physical withdrawal symptoms, does not mean one is automatically qualified for insurance coverage for treatment. Medical detox will be covered but may be offered in the form of outpatient methadone treatment or buprenorphine, depending on the addiction dose of heroin.
If outpatient detox methods are approved, it will be difficult to get coverage for inpatient addiction treatment. Even if inpatient medical detox is covered, it does not guarantee coverage for inpatient drug rehab.
Yes. Not every drug rehab program will work with all insurance companies. Even if a drug rehab does worth with your insurance provider, its ability to get paid is only as good as its staff. It requires organization, patience, and follow-through to push a reluctant insurance company to provide payment for treatment. This requires well-trained and dedicated staff in the billing department.
Yes. When you invest in drug rehab, you are investing in your loved one’s ability to take care of themselves. The payback often comes in the form of money no longer spent on legal fees, missed work, and health care costs related to active addiction. When your loved one can get back on track, begin working, and contributing to the family, the financial situation eases even more.
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(2018) NCQA Health Insurance Plan Ratings 2018 – 2019. National Committee for Quality Assurance. from from http://healthinsuranceratings.ncqa.org/2018/Default.aspx
(December 2018) Medical Necessity Definition in Health Insurance. Verywell Health. from from https://www.verywellhealth.com/medical-necessity-1738748
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(February 2016) Understanding Drug Abuse and Addiction: What Science Says – 8: Medical detoxification. National Institute on Drug Abuse. from from https://www.drugabuse.gov/publications/teaching-packets/understanding-drug-abuse-addiction/section-iii/7-medical-detoxification