Should I Go To Rehab Now That My Deductible Is Met?

Ideally, the decision to go to rehab wouldn’t be based on health insurance or the associated costs. However, it is for many people, due to the mounting costs of health care.

Knowing the extent of your health insurance coverage and the amount you’ll be responsible for paying can help you better plan for treatment. This article explores different health insurance costs, such as copayments, coinsurance, deductibles, out-of-pocket maximums, and monthly premiums, and how going to rehab after meeting the deductible may amount to cost savings.

Does Health Insurance Cover Addiction Treatment?

More than half of all Americans know someone who is in recovery from a drug or alcohol addiction, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). To better serve the millions of people with SUDs, private insurance companies are required by law to offer plan holders access to some substance abuse and mental health treatment services.

Private insurance is insurance provided through an employer or purchased directly by individuals or families. The Affordable Care Act (ACA) made it unlawful for insurance companies to define limits for SUD treatment that aren’t also defined for medical or surgical benefits. In other words, the benefits available for medical or surgical services are offered at the same tier for SUDs.

Health insurance may cover some or all of a rehab center stay. The amount of coverage depends on factors such as the insurance provider, the plan chosen, whether the rehab facility is in-network or out-of-network, and if the individual has met their deductible and/or out-of-pocket maximum.

What Is A Health Insurance Deductible?

A health insurance deductible is the amount of money that an individual or family must pay for covered healthcare services before their insurance pays for the costs. If someone has a plan with a $1,500 deductible, for example, they must pay out of pocket for services until the total amount paid is $1,500. The deductible resets annually, usually at the beginning of the calendar year, and can change from year to year. Some plans have different deductibles for using in-network and out-of-network providers, and others don’t have deductibles at all. Family insurance plans typically have separate deductibles for each individual and the family as a whole.

If you meet your deductible, it doesn’t mean that all subsequent healthcare services are free. After meeting the deductible, plan holders usually pay copayments (copays) or coinsurance. In fact, you will continue paying copays and/or coinsurance until you meet your out-of-pocket maximum for the year.

If I Paid My Deductible, Is Rehab Free?

While going to rehab after meeting your deductible is a more cost-effective way to receive treatment, it doesn’t mean that rehab will be free. The deductible is only a portion of the out-of-pocket costs associated with health insurance. As mentioned, after you pay your deductible, you’ll continue paying copays and coinsurance until you meet the out-of-pocket maximum for the year. If your plan has separate deductibles for in-network and out-of-network providers, and you attend an out-of-network facility, then you’ll have to pay more for services there. If you reach the out-of-pocket maximum and then go to rehab, your plan will pay for all costs and services. So, no, if you paid your deductible, rehab will not be free, but if you meet your out-of-pocket maximum, then it will be.

Other Health Insurance Costs: A Breakdown

Aside from paying a deductible, there are other costs associated with health insurance plans, including those that continue after the deductible is met.

Copayments

Copays are fixed out-of-pocket costs for covered healthcare services. Copays are typically due at the time of service and apply even if the plan holder hasn’t met their deductible yet. Copays do not count toward the deductible, but they do count toward the out-of-pocket maximum.

The cost of copays varies based on the service. For example, the copay for a primary care physician visit may be $30, while a visit with a specialist is $50, and an emergency room visit is $120. (Note: The exact cost will depend on your coverage.) If the individual did not reach their deductible yet, then they would pay the full cost of care, such as $120 for a visit with their physician, the highest allowable cost for this service under their health plan, for example. You will continue paying copays until you’ve met your out-of-pocket maximum. Fortunately, many providers cover preventative services in full regardless of the deductible or copays, such as vaccinations and cancer screenings.

Coinsurance

Coinsurance is another out-of-pocket cost in addition to copays. It refers to the percentage of services that are paid by health insurance and the percentage paid by the plan holder. If someone has an 80/20 plan, then their insurance covers 80% of the cost of a service, and the remaining 20% is the plan holder’s responsibility. Unlike copays, coinsurance only kicks in after the deductible is met, and the same percentage applies to all services.

Out-Of-Pocket Maximum

The out-of-pocket maximum is the amount that determines when a plan holder has reached their spending limit for the year. Once the out-of-pocket maximum is met, all services are fully paid by the health insurance provider. While meeting the out-of-pocket maximum sounds ideal, it isn’t necessarily easy to do unless you’re significantly utilizing services.

The out-of-pocket maximum varies depending on whether a person has employee-provided insurance or if they purchased their insurance from the Health Insurance Marketplace. For example, the maximum for someone who purchases insurance through the Marketplace may be $9,000, while the maximum for an individual with employee-paid insurance may be half that amount. The out-of-pocket maximum must be met before insurance covers the cost of all services fully. The deductible, copay, and coinsurance all counts toward the out-of-pocket maximum.

Monthly Premiums

The monthly premium is the amount paid per month for health insurance coverage. The premium is typically lower for people who have insurance through their employers and higher for people who purchase it through the Marketplace. In regard to specific plans, typically the higher the monthly premium, the lower the deductible, and vice versa. The monthly premium does not count toward the out-of-pocket maximum and is a recurring cost per month.

Other Than Rehab, What Can My Insurance Cover For Addiction Treatment?

There are several services that your insurance may cover aside from inpatient rehab. According to HealthCare.gov, all plans available on the Marketplace are required by law to offer mental health and substance abuse treatment services as essential benefits.

Some of the services that are covered in full or partly by insurance include:

• medical detox
• outpatient treatment
• medication-assisted treatment
• therapy
• treatment for co-occurring disorders

While insurance providers are required to offer these benefits, that doesn’t mean these services are free of charge. The cost depends on the state you purchased the benefits; if you purchased benefits in Massachusetts and recently moved to North Carolina while under that same plan, the benefits will pertain to Massachusetts. The cost also depends on the type of plan you purchased, such as whether it’s a health maintenance organization (HMO) or preferred provider organization (PPO) plan.

Find Freedom From Addiction

If you are dealing with a drug or alcohol addiction, you don’t have to handle it alone. Help is available whenever you’re ready. Call Bedrock Recovery Center for more information and to verify your insurance today.