Introduction to Blue Cross Blue Shield of Massachusetts
If you’re covered by Blue Cross Blue Shield of MA, you should learn what’s relevant to you about treatment coverage now. It’s important to take care of rehab insurance before you enter treatment.
That way, once you’re there, you can focus on what’s important—getting better.
About Blue Cross Blue Shield of Massachusetts
You might have questions about how your Blue Cross Blue Shield of MA coverage works and how to learn what your plan covers.
Every rehab health insurance plan is different, so we can’t predict what your Blue Cross Blue Shield of MA coverage may entail. However, you can get the specifics on your plan by knowing where to look for those details.
Here are the basics on paying for addiction treatment with Blue Cross Blue Shield of MA:
Will My Addiction Treatment Be Covered By My BCBSMA Insurance Plan?
It’s likely (but not 100% certain, as there are exceptions) that Blue Cross Blue Shield of MA will cover substance abuse treatment.
Blue Cross Blue Shield of MA has to abide by the Affordable Care Act of 2010. That act prevents insurance companies from discriminating when they make decisions about covering medically-necessary treatment for people with pre-existing conditions.
People with substance use disorders are considered to have pre-existing conditions, which means health insurers are required to cover medically-necessary addiction treatment, including Blue Cross Blue Shield of MA.
How Much Does Blue Cross Blue Shield of MA Cover?
That coverage could be full (the insurance company pays 100%, you pay none of the cost) or partial (the insurance company pays a portion and you pay a copay or coinsurance fee). It depends on your policy and plan.
Blue Cross Blue Shield of MA may not cover your treatment if:
- You Don’t Adhere to the Required Prior Authorization Process : Most insurance companies, including Blue Cross Blue Shield of MA, require a prior authorization before they’ll approve coverage for costly services like addiction treatment. This simply means that your healthcare provider needs to provide them with certification that addiction treatment is necessary for you.
- You Don’t Get a Required Referral From a Primary Care Provider : Similarly to the prior-auth process, Blue Cross Blue Shield of MA might ask you to see a primary care provider before seeking treatment. The provider’s referral helps the insurance company decide to cover your treatment.
- You Have an Exempt Short-Term or Temporary Policy : If you have a Blue Cross Blue Shield of MA policy that’s only supposed to last a few weeks or months between long-term policies, you probably do not have coverage. However, this doesn’t apply to most policies. The only way to know for sure that your treatment is covered by Blue Cross Blue Shield of MA is to check your specific coverage.
How to Check Blue Cross Blue Shield of MA Addiction Treatment Coverage
It’s important to check your plan with Blue Cross Blue Shield of MA before you enter treatment for substance use disorder.
Check Coverage Directly From Blue Cross Blue Shield of MA
Blue Cross Blue Shield of MA makes it easy for members to contact them or get more information about a plan or a policy.
First, members can log into the members-only portal online to find coverage information on their own.
Next, you can call the Member Services phone number listed on your insurance card. They can route you to the correct information about your Blue Cross Blue Shield of MA policy and coverage.
Even if you find what you need on the members portal, it’s a good idea to call Member Services. If your policy has conditional coverage or partial coverage, it’s important to know all the details going in.
Talk to Treatment Admissions About Coverage
Finally, you can talk to the admissions office at your rehab of choice. It’s common for admissions offices to act as a third party to contact your insurance company. Let them know that you’re interested in finding out if:
- They’re in-network
- They accept your insurance
- Their programs are covered by your policy
The admissions team at your rehab calls Blue Cross Blue Shield of MA and finds all the answers for you, then gets back to you regarding your coverage.
There are a couple of benefits to taking this approach. First, you don’t have to find the time to call an insurance phone line and wait on hold.
Second, your treatment center of choice has all your insurance information from the get-go. This means faster intake so you can start recovery as soon as possible.
How Does Blue Cross Blue Shield of MA Rehab Coverage Work?
Your insurance policy with Blue Cross Blue Shield of MA works in the same way that medical coverage works across the board.
Step 1: File a Claim Before Entering Treatment
Once you decide you’re ready to attend treatment and you’ve selected a treatment center, you’re responsible for notifying Blue Cross Blue Shield of MA so they can process your claim. You need to do this before entering treatment to ensure coverage.
In many cases, the treatment center you’re attending handles all claims processing for you. That includes all the paperwork and phone calls!
If you already know where you’re attending treatment, call them right away. The Admissions office can help you navigate the claims process so you can focus on recovery, not insurance.
Step 2: Get Prior Authorization for Addiction Treatment
Nearly all Blue Cross Blue Shield of MA policies require prior authorization before they’ll approve coverage of high-cost services like addiction treatment.
Your insurance company may need proof that treatment is medically necessary as a condition of coverage. That proof is as simple as a pre-authorization form or a referral from your family doctor.
That means a medical professional must certify that your substance use disorder requires treatment. You can see your primary care doctor or behavioral healthcare specialist for this.
Step 3: Determine Your Financial Responsibility
After the insurance company processes your claim, they’ll send you a financial responsibility statement that outlines your portion of the cost. That’s the amount that you’re responsible for paying.
Depending on your coverage, treatment center, and program, that could be as little as $0, or more commonly, a few hundred or thousand dollars.
Do Blue Cross Blue Shield of MA Insurance Plans Cover Addiction Treatment?
Your health insurance plan with Blue Cross Blue Shield of MA is very likely to cover addiction treatment. It’s just a matter of:
- How much is covered
- What types of treatment programs are covered
- What processes you must follow to get covered
In 2010, the Affordable Care Act was passed. The Act means that insurance companies can’t discriminate against people who have pre-existing conditions, including substance use disorder. (In the early 2000s, insurance companies routinely denied addiction treatment coverage.)
That means all health insurance companies must cover medically-necessary treatment for substance use disorder, including Blue Cross Blue Shield of MA.
Does Blue Cross Blue Shield of MA Cover Addiction Treatment 100%?
The coverage Blue Cross Blue Shield of MA provides can be full (you pay 0% of the cost) or partial (you pay a part of the cost, called a copay or coinsurance.)
Most insurance plans don’t cover addiction treatment at 100%, but some plans that are part of a Health Maintenance Organization (HMO) may.
These plans tend to pay for treatment at higher rates. If your Blue Cross Blue Shield of MA plan is an HMO, give Member Services a call by dialing the phone number on your insurance card.
They can give you an idea of whether 100% coverage is possible, and help you with next steps if it’s not.
What Types of Treatment Programs Does Blue Cross Blue Shield of MA Cover?
Blue Cross Blue Shield of MA covers all types of addiction treatment programs that can be called medically necessary.
That includes detox programs, residential inpatient programs, and medication-assisted treatment programs.
Insurance Coverage for Detox Programs
Your insurance company considers detox programs medically necessary. Without them, your risk of relapse increases dramatically, especially with opioids or alcohol. For that reason, Blue Cross Blue Shield of MA is likely to cover detox treatment programs. The programs they cover may need to be in network, and they must follow care standards.
The amount of coverage depends on your policy and plan, so it’s impossible to say how much of the cost of detox is covered. For exact details about your coverage, contact Blue Cross Blue Shield of MA.
Insurance Coverage for Residential and Inpatient Programs
Because it’s so effective at reducing relapse, residential treatment is considered medically necessary, so it’s covered.
Without entering a program, your risk of relapse is 90% within a year after stopping substance use. Entering treatment reduces that risk to 60%.
Blue Cross Blue Shield of MA covers inpatient rehab programs to different degrees. The covered programs need to provide approved care and follow rigorous standards.
Some plans may have 100% coverage, but most plans offer partial coverage with coinsurance or a copay.
Your own coverage is impossible to predict, so call the phone number on your insurance card to find out.
Insurance Coverage for Medication-Assisted Treatment Programs
Medication-assisted treatment is considered medically necessary for long-term recovery and acute treatment. That’s why Blue Cross Blue Shield of MA typically covers these programs.
Some of the MAT services covered include:
- Opioid maintenance therapy using buprenorphine, methadone, or naltrexone
- Alcohol maintenance therapy using disulfiram, naltrexone, or acamprosate
- Behavioral therapy, which is often used alongside MAT to make it more effective
Blue Cross Blue Shield of MA usually covers MAT on an outpatient or inpatient basis. Sometimes MAT programs are part of residential programs that are also covered.
Talk to your addiction care provider right away if you’re interested in MAT. They’ll help you navigate the prior authorization process to get your medication and therapy covered.
What Types of Addictive Substances Are Covered By Insurance?
You should contact Blue Cross Blue Shield of MA to learn the exact details of your coverage, since it’s different for each plan. But in general, your insurance plan should cover substance abuse treatment for any substance that causes dependence.
For instance, your Blue Cross Blue Shield of MA plan may cover treatment for:
- Alcohol use disorder
- Opioid use disorder, which includes heroin and prescription narcotics like tramadol and oxycodone
- Stimulant use disorder, which includes cocaine, meth, and prescription stimulants like amphetamine or methylphenidate
Generally, Blue Cross Blue Shield of MA is flexible about the exact substance that’s involved in the diagnosis. As long as a doctor says that treatment is medically necessary, insurance usually covers substance use disorder with any dependence-causing drug.
That’s because substance use disorder (SUD) is an umbrella diagnosis. There are many types of SUD, and because they’re a SUD, they’re covered for treatment. It doesn’t matter what substance you stopped using because the disorder (SUD) is the same.
Again, it’s impossible to say what your exact coverage is, so call Member Services at the phone number on your insurance card to learn what’s covered and to what degree. But you shouldn’t expect to have a hard time getting covered based on the type of substance.
Do Treatment Centers Need to Be In-Network?
Whether you need to attend an in-network treatment center depends on your plan. There are two types of plans that have their own policies for provider networks.
Health Maintenance Organization In-Network vs. Out-of-Network
If your Blue Cross Blue Shield of MA plan is a Health Maintenance Organization (HMO), then you must choose treatment with a provider that’s in-network. If you choose an out-of-network provider, your insurance company won’t cover treatment.
With an HMO, your costs tend to be low, even though your options are less flexible.
When you stay within the network of preferred providers, your Blue Cross Blue Shield of MA Plan may cover a higher portion of treatment, or even all of it. Your copays and coinsurance are typically smaller than they would be under a PPO.
Preferred Provider Organization In-Network vs. Out-of-Network
Preferred Provider Organizations (PPO) allow you to choose an out-of-network treatment provider. With a PPO, you’ll have a lower end cost if you choose a provider who’s in-network. PPOs still cover out-of-network providers, but at a higher cost to you.
In exchange for that added flexibility, using a PPO plan typically means higher costs compared to an HMO.
With a PPO, you have lower copays and coinsurance when you stay in-network—but they still tend to be costlier than an HMO. Those prices rise when you move out-of-network, but a portion is covered.
How Can I Pay the Costs Not Covered By My Blue Cross Blue Shield of MA Plan?
Once you have your statement of financial responsibility, you might find that there’s a gap between what you can pay and what costs remain.
If that’s the case, don’t panic or cancel your treatment plans. There are plenty of resources available to you that can help cover the costs of addiction treatment.
Health Savings Account
A Health Savings Account is an account that accrues pre-tax income that you can spend on healthcare purposes. You might have an HSA if you have insurance through your employer, or if your plan is high-deductible.
If you have an HSA, you may be able to use the balance to pay for some parts of addiction treatment.
This balance is not the same as your regular coverage, even if the HSA is part of your Blue Cross Blue Shield of MA plan. Even if you’ve exhausted your coverage, you can use your HSA as long as your policy allows it.
Check with Blue Cross Blue Shield of MA to find out if your HSA allows spending on addiction treatment.
Flexible Spending Account
A Flexible Spending Account is similar to a Health Savings Account, but it disappears at the end of the year if you don’t use it!
Like HSAs, most people who have FSAs have a high-deductible plan or an employer-subsidized plan.
It depends on your policy and plan, but you may be able to pay for your treatment balance with your FSA funds. If it’s allowed, this is an effective way to avoid losing FSA dollars at the end of the year.
If your Blue Cross Blue Shield of MA plan also provides your FSA, you can still use your FSA to pay the balance after your coverage is applied, as long as addiction treatment is an allowable expense.
There are a number of private organizations that support people in recovery by funding rehab scholarships.
These scholarships are different depending on who’s offering them, but typically, you may qualify if you:
- Want to recover from substance use disorder
- Are working toward long-term recovery
- Can’t afford substance use treatment
The most well-known national rehab scholarship is 10,000 Beds, but there are many recovery organizations on the local level that offer rehab support. Some churches and spiritual chapters with recovery communities offer scholarships, too.
Reach out to as many organizations as you can, since these scholarships tend to be very competitive with long waitlists. You might get a response faster if you contact more people who can help.
Every state government funds programs for low-income addiction treatment.
These programs are low-cost or free, but:
- They have long waitlists
- They have restricted budgets, which translates to fewer staff and resources
- You have no say over where you attend treatment
If you’re in a crisis and you can’t make any alternative work, then by all means, reach out to a state program. Your safety is the most important.
However, keep in mind that these programs tend to be overworked and underfunded. Private rehabs offer fast admission, plenty of staffing, and choice over your treatment, making them a preferable choice if you can manage.
You may be surprised to find the number of local resources for addiction in your area! Nearly any community-based or spiritual community has recovery support if you look for it.
Start with communities such as:
- 12 Steps groups
- Recovery groups
- Churches, temples, and mosques
- Mental health support groups
- Family support groups
Even if the organization you reach out to can’t help financially, they can point you in the right direction.
Talk to Your Treatment Center
If you’ve tried everything and you’re not sure where else to try, talk to your treatment center.
Some private treatment centers offer financing, payment plans, or even payment forgiveness. Talk to Admissions as soon as you can. They’ll be able to help you figure out how to handle your remaining balance.
Addiction Treatment Begins at Bedrock
Once you’ve got coverage figured out, it’s time to start the journey to recovery.
Bedrock Recovery Center is where you can find the best drug and alcohol addiction treatment in MA. Nestled in cozy Canton close to urban amenities, our evidence-based treatment plans are tailored to you and your needs.
Reach out to our Admissions team to learn how to navigate your Blue Cross Blue Shield of MA insurance plan!
Bedrock Recovery Editorial Team
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This page does not provide medical advice.