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Will Insurance Pay for Drug Detox?

Do Insurance Companies Pay for Drug Detox?

Often, yes. Private insurance companies are now required by the Affordable Care Act (ACA) to provide some form of substance abuse treatment coverage to their members. The ACA also regards substance abuse treatment as an essential health care benefit for US citizens. This means most insurers can’t completely deny substance use disorder coverage. Your specific coverage, however, will depend on the state you purchased benefits in and the particular health care plan you chose, such as a PPO or HMO plan.1

Insurance companies may ask their members to choose from a small set of approved or “in-network” providers, ensuring that treatment comes at a lower cost. They may also ask members seeking detoxification services and other types of addiction treatment to pick up some costs required for care in the form of premiums, deductibles, and copayments.

AAC is in-network with many insurance companies and your addiction treatment can be free depending on your policy and deductible.

The Affordable Care Act & Drug Rehab The Affordable Care Act & Drug Rehab

Currently, concerns regarding insurance coverage (or lack thereof) serve as a barrier to people suffering from addiction receiving the treatment they need, despite increasing coverage.2 In fact, only one in ten people suffering from a substance use disorder get the appropriate treatment they need. Unfortunately, payment issues and lack of insurance are among the reasons for this disparity.3

Mental illnesses and, thus, mental health and addiction treatment, have become less stigmatized in recent years, partially due to the ACA. Still, a few insurance companies may still make it difficult for those suffering from addiction to receive the help they need.

In the past, many insurance companies did not cover substance abuse treatment of any kind. Insurance companies also used to be able to deny coverage for addiction treatment, either entirely or partially, to members based on whether their substance use disorders or other co-occurring mental health conditions were considered “pre-existing conditions”.

When President Obama signed the Affordable Care Act (also referred to as Obamacare) in 2010, it encouraged a wave of change that was already preemptively occurring within many insurance companies. The ACA requires that all plans it encompasses provide coverage for mental and behavioral health services, including substance abuse treatment.1

How much an insurance company covers detox programs and rehab still depends on someone’s individual plan and the treatment program they choose. In some cases, a person looking to receive treatment must attain a referral from their primary care physician before their insurance provider will pay for treatment.

In addition, the ACA also mandated that such policies cover the treatment of mental illness. Many people who struggle with addiction and substance abuse issues also struggle with a co-occurring mental health disorder, such as anxiety or depression. Treatment medications, therapy, and even time spent in residential drug rehab facilities on an inpatient basis are often covered.4

Obamacare served as a catalyst for destigmatizing mental health in U.S. society and the health insurance industry. Through its new regulations and resulting insurance reform, it was able to establish mental health treatment as a valid and necessary need for coverage.

Medicaid, Medicare, and Addiction Treatment

Those who have Medicaid are now covered for substance abuse treatment through the ACA, too. Medicaid is federally covered insurance for those with low incomes. Nearly 12% of adults who are recipients of this insurance have a substance use disorder, making the expansion of mental health coverage even more vital.5

Medicare, on the other hand, is federally provided health insurance for those who are 65 years of age or older, or under the age of 65 with a disability. Medicare covers treatment for alcohol use disorder and other substance use disorders under a set of conditions:6

  • The provider states the services provided are medically necessary.
  • You receive services at a facility in-network and approved by Medicare.
  • Your provider sets up your care plan.

Not every substance abuse and mental health treatment center accepts Medicaid and Medicare for coverage, so be sure to reach out to your desired provider to understand your specific treatment options.

Does Insurance Pay for Rehab & Detox?

Some insurance plans cover 100% of detox and treatment expenses once a member meets their deductibles. Other insurance providers require that insured members pay copayments for each service the facility charges the company for. Out-of-network treatment facilities may sometimes cost insured members the most.

The detox process varies depending on the substance(s) used, and likewise, the amount of the costs covered by insurance will vary according to the process chosen and the individual’s specific plan. For example, a non-medical detox may be less costly than a hospital-based detox facility.

While insurance companies may have to offer coverage for substance abuse treatment, they don’t necessarily have to cover inpatient treatment. If outpatient care is not successful then inpatient care might be deemed medically necessary. Medical necessity is when an insurance company determines that a physician would give the patient after exercising prudent clinical judgment.

You can verify your insurance with AAC and learn more about addiction treatment plans and insurance coverage.

How Long Does Insurance Cover Rehab?

Insurance companies will utilize several criteria when determining the coverage they provide to a patient.7The insurance company will likely work with your doctor or treatment provider to determine the necessary treatment and decide what they will cover and for how long.

There are multiple levels of care involved in addiction treatment, and you may be covered for one or more of these programs. Some plans will only cover a detox stay, while others may provide coverage for many levels as a patient moves through the continuum of care (e.g., from detox to inpatient rehab to outpatient therapy).7

Detox and rehab providers will perform a thorough assessment of the needs of someone suffering from a substance use disorder. Throughout a patient’s treatment stay, they may be routinely assessed by their clinical team to determine where they are experiencing improvement or struggling in treatment.8 Based on these assessments, along with their own criteria for payment approvals, insurance companies may decide to extend someone’s treatment coverage.9

Is Residential Treatment the Same as Inpatient Treatment?

Inpatient drug rehabilitation encompasses multiple levels of care, while residential treatment is a subcategory of inpatient drug rehabilitation. There are varying programs that form inpatient care, ranging from detoxification to residential care.

Detoxification, also called withdrawal management, is generally considered the first step in receiving inpatient treatment for a substance use disorder or relieving physical dependence on a drug.

Once a substance is fully eradicated from the patient’s body, they may choose to proceed to residential care. In residential care, a patient may participate in behavioral therapies effective for treating substance use disorders, such as:

Aftercare: Is Addiction Therapy Covered by Insurance?

Widespread insurance coverage is available for outpatient treatment and aftercare providers. That being said, there are time limits imposed by many insurance policies on both outpatient and inpatient care. While some insurance companies offer policies that extend treatment coverage for up to six months or a year, others may stop coverage after days or weeks. It’s important for clients to verify their coverage with the chosen treatment facility and their insurance provider before committing to a specific treatment plan.

Detox alone is rarely enough to ensure lasting recovery. Brief inpatient stays also may be insufficient in the absence of aftercare.12

Outpatient programs and continuing care plans are a large part of treating substance abuse and addictions. These programs help many people recovering from substance abuse stay sober for the long term. Typically, mental health services are covered by insurance; however, it’s important to verify coverage specifics.

Popular methods of therapy known to treat addiction include:13

  • Cognitive behavioral therapy (CBT).
  • Group therapy.
  • Family counseling.
  • Vocational rehabilitation.

The therapeutic models mentioned above are generally covered by most insurance providers, so long as it is approved by the American Psychological Association.13

Holistic regimens and practices, such as guided meditations, may not be covered by insurance providers. However, this doesn’t mean these methods aren’t effective or useful to some people recovering from substance use disorders. In fact, mindfulness may be a promising approach to managing and treating addictive disorders, but more studies must be done on this topic to say for certain.14

Another viable option for continuing care is the incorporation of 12-step programs. 12-step programs encourage people to accept their substance use disorder as a disease, as opposed to a moral failing. 12-step programs also strive to minimize self-centeredness in their participants and prompt members be of service to others early in recovery or currently living in active addiction.15

Overall, having health insurance is highly correlated with the likelihood that someone will seek treatment for substance abuse. Where addiction used to be considered a social or criminal issue, it’s finally being recognized as a disease.16 Considering almost 22 million people in the United States were considered to have had a substance use disorder in 2017, insurance coverage for addiction treatment, and easy access to treatment providers, is more crucial than ever.17

 

Sources:

  1. US Department of Health and Human Services (2020). Mental Health and Substance Abuse Treatment.
  2. Magellan Health (2016). Evidence-Based Practices in Drug and Alcohol Treatment and Recovery.
  3. US Department of Health and Human Services (2016). Facing Addiction in America.
  4. National Institute on Drug Abuse (2012). Principles of Drug Addiction Treatment.
  5. Centers for Medicare and Medicaid Services (2012). Substance Use Disorders.
  6. Medicare Rights Center (2020). Treatment for Alcoholism and Substance Use Disorder.
  7. Cigna Health and Life Insurance Company (2020). Medical Necessity Definitions
  8. Aetna Inc. (2020). Screening, Brief Intervention, and Referral to Treatment.
  9. American Society of Addiction Medicine (2013). Advancing Access to Addiction Medications.
  10. American Society of Addiction Medicine (2020). About the ASAM Criteria. 
  11. National Institute on Drug Abuse (2018). Types of Treatment Programs.
  12. Substance Abuse and Mental Health Services Administration (2015). TIP 45: Detoxification and Substance Abuse Treatment.
  13. American Psychological Association (2013). Breaking Free from Addiction. 
  14. Zgierska, A., Rabago, D., Chawla, N., Kushner, K., Koehler, R., & Marlatt, A. (2009). Mindfulness meditation for substance use disorders: a systematic review.
  15. Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, D. C. (2013). 12-step interventions and mutual support programs for substance use disorders: an overview.
  16. Substance Abuse and Mental Health Services Administration (US) Office of the Surgeon General (US) (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health
  17. Substance Abuse and Mental Health Agency (2014). Trends in Substance Use Disorders Among Adults Aged 18 Or Older.
Last Updated on September 3, 2020
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Ryan Kelley, NREMT
Industry Expert
Ryan Kelley is a nationally registered Emergency Medical Technician and the former managing editor of the Journal of Emergency Medical Services (JEMS).
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