Introduction to Insurance Treatment Coverage
That means if your provider and insurer agree that an addiction treatment program is medically necessary for you, the program is probably covered.
However, the guidelines for deciding whether to cover a type of treatment are different from insurer to insurer.
You can get an idea of what types of rehab treatment programs may be covered because the Affordable Care Act tells us the legal criteria for covering treatment.
Despite that, there’s some grey area that leaves some room for differences in coverage from insurer to insurer. Verify insurance plan coverage with us before you choose a type of addiction program.
What Types of Addiction Treatment Programs Are Covered by Insurance?
Your insurance provider decides which addiction treatment program types to cover by using some specific criteria.
The guidelines they use include:
- Whether you have the right diagnosis for the treatment type.
- Whether the treatment type is effective and medically necessary for your diagnosis.
- Whether the treatment type is evidence-based and approved by the FDA (U.S. Food and Drug Administration).
- Whether you follow insurance guidelines and procedures for showing that the treatment type is medically necessary.
Because the criteria aren’t simple, it can be hard to predict what types of treatment your insurer covers.
Despite that, you can make a guess using the right information about treatment coverage, and call Bedrock to verify the types of addiction treatment your insurance plan covers.
Does Insurance Cover Detox Rehab Treatment?
Insurance companies are required to cover medically-necessary addiction treatment types, including detox programs.
These programs are critical for addiction patients because they provide a safe place to withdraw from substances with support.
Because they’re so important, detox programs are almost always covered as medically necessary addiction treatment, as long as your plan is subject to the Affordable Care Act.
Detox rehab programs are often covered by insurance plans for people with:
- Alcohol use disorder
- Opioid use disorders, including heroin and prescription drugs
The exact services that your plan covers vary depending on your plan and policy, but may include:
- A stay in an approved detox facility
- Medications to control withdrawal symptoms, e.g. muscle relaxers for pain, or anti-anxiety medications for mood changes
- Intravenous hydration, or IV fluids to combat the dehydration from withdrawal
- Nutritional services to address the vitamin and macronutrient deficiencies that you can get from long-term addiction
- Therapy and counseling for emotional support during this challenging part of recovery
No two plans or policies cover exactly the same services to the same degree, so it’s important to reach out to us to verify insurance coverage, which may be partial or full.
Does Insurance Cover Inpatient Residential Rehab Treatment?
Most insurance plans cover inpatient or residential drug addiction treatment types.
Inpatient rehab program types are usually medically necessary for addiction treatment, which means insurance companies are typically required to cover them.
To get covered, the process often requires that you have a diagnosis of:
- Substance use disorder
- Stimulant use disorder
- Opioid use disorder
- Alcohol use disorder
- Or any type of substance use disorder
Residential programs are a medically necessary part of addiction treatment no matter what substance you’re recovering from using. As long as your doctor can prove to insurance that you need a residential program type, it’s likely to be covered.
Inpatient services can be very different from program to program. The services that are covered with this program type can include:
Make sure to verify your insurance coverage before you make any decisions about paying for your program or choosing a program type.
Does Insurance Cover Medication-Assisted Rehab Treatment?
It’s very common for insurance companies to cover medication-assisted treatment programs.
In fact, long-term plans are required to cover medication-assisted treatment as medically necessary addiction treatment under the Affordable Care Act.
The types of medication-assisted treatment programs that are covered vary depending on:
- Your diagnosis (e.g. MAT for opioid use disorder is likely to get coverage, but MAT for stimulant use disorder almost never does)
- Whether your doctor can demonstrate that it’s medically necessary
You should always double-check your insurance coverage before you choose a type of addiction program. Your exact coverage varies depending on your plan, policy, insurer, and more.
Some commonly-covered MAT program types include:
Medication-Assisted Treatment for Alcohol Addiction
It’s likely that your insurance plan covers medication-assisted treatment for alcohol addiction.
This type of treatment is considered evidence-based and accepted for treating alcohol use disorder, so most insurance companies cover it.
Still, always contact Bedrock Recovery Center to verify the types of substance abuse treatment that are covered by your insurance plan. The specifics can vary by plan, policy, and insurer, and even the provider you choose.
The services that your insurer might cover in this type of treatment program include:
- Routine appointments: Most MAT programs require you to attend frequent appointments to check on your recovery progress and receive medication.
- Urine and blood testing: Your coverage may include routine blood or urine testing as part of your MAT program. The tests (but not the results) are usually a condition of treatment coverage and staying in the program.
- Acamprosate: Also known as the brand name Campral, your insurance coverage may include acamprosate for alcohol MAT. This medication prevents or lessens withdrawal from alcohol.
- Disulfiram: Also called Antabuse, this medication is a deterrent that makes your body hypersensitive to ethanol, the active chemical in alcohol. When you take disulfiram, drinking any amount of alcohol at all triggers a severe hangover reaction.
- Naltrexone: Sold as Vivitrol, naltrexone is an injectable medication that can block the effects of alcohol within minutes and reduce cravings over days or weeks.
- Behavioral therapy: Your insurance company will most likely require behavioral therapy as a condition to cover your treatment. That’s because MAT programs are only evidence-based when they include behavioral treatment, like therapy or counseling.
The coverage you receive can be full or partial depending on your plan type. Your insurance company can let you know how much of your medication-assisted treatment is eligible for coverage.
Medication-Assisted Treatment for Opioid Addiction
Insurance companies almost always cover medication-assisted treatment for opioid addiction as long as it’s considered medically necessary.
If your substance problem involves heroin addiction or prescription pain medications, then your insurance company will probably cover MAT.
Your insurer may want to know that you have a diagnosis of substance use disorder or opioid use disorder, which you can get from your primary care doctor.
The MAT services and medications that may be covered for heroin or prescription opioids can include:
- Routine appointments: Most programs require daily (or frequent) appointments to receive medication, at least at first. Your insurer will likely cover any routine appointments as part of MAT.
- Blood and urine tests: Urine tests and less commonly, blood tests are often covered as part of MAT. Urine tests are usually routine, while blood tests are infrequently used (but still usually covered).
- Buprenorphine: You may know this medication as the brand name Subutex. Buprenorphine is usually covered for MAT treatment if you have opioid use disorder. It treats opioid use disorder by blocking the opioid receptors in your nervous system.
- Naltrexone: Most insurers cover naltrexone, or Vivitrol. This injection medication blocks the effects of opioids and can reduce cravings, which increases treatment success in MAT.
- Methadone: Also called Methadose, this medication is often covered for opioid MAT. It’s taken by mouth as a liquid and blocks the potential for opioid withdrawal.
- Behavioral therapy: Most insurance companies require behavioral therapy, like cognitive-behavioral therapy, to be part of the MAT program in order to get coverage. That’s because MAT is more effective when it’s paired with therapy.
You may have partial or full coverage for MAT services if they’re medically necessary for you. Call Bedrock Recovery Center to learn the exact details of your coverage, including copays and coinsurance for medications.
Does Insurance Cover Medication-Assisted Treatment for Stimulant Addiction?
Most insurance companies do not cover medication-assisted treatment for stimulant addiction, which includes methamphetamine, cocaine, and prescription stimulants like Adderall (amphetamine) or Ritalin (methylphenidate).
As of 2020, there are no medications that are approved to treat stimulant use disorder, stimulant dependence, stimulant abuse, or stimulant withdrawal.
Insurance companies only cover treatment that’s evidence-based and recognized as safe and effective.
Until there’s a medication like that for stimulant use disorder, your insurance company won’t cover MAT for stimulants, like meth or cocaine addiction.
Call to verify your insurance to find out which treatment types are approved for stimulant use disorder.
Does Insurance Cover Medication-Assisted Treatment for Prescription Drug Addiction?
It’s common for insurance to cover MAT for opioid pain medications.
You may be eligible for coverage if your substance use disorder involves any of these medications:
- Codeine (generic)
- Fentanyl (branded Duragesic)
- Hydrocodone (branded Vicodin or Norco when it also contains acetaminophen, which is not an opioid but can cause overdose)
- Methadone (branded Methadose or Dolophine)
- Morphine (branded MS Contin or Morphabond)
- Oxycodone (branded OxyContin or Percocet when it contains acetaminophen)
- Oxycodone and naloxone (generic)
- Tramadol (generic)
Insurance typically does not cover medication-assisted treatment for non-opioid prescription medications.
If your prescription drug disorder involves any of the following medications, you probably will not get coverage for MAT:
- Benzodiazepines, such as Ativan, Valium, or Xanax
- Stimulant medications, such as Adderall, Ritalin, Vyvanse, or Concerta
- Sedative-hypnotics, such as Ambien, Sonata, or Lunesta
You might still get coverage for other types of treatment (like residential or detox) if you’re not covered for MAT, so check with Bedrock to find out.
Does Insurance Fully Cover All Types of Addiction Treatment Programs?
Insurance plans fully cover all types of addiction treatment that are medically necessary.
The Affordable Care Act of 2010 made it illegal for insurance companies to discriminate by refusing to cover medically necessary treatment for pre-existing conditions like substance use disorders.
If your insurance plan is a long-term plan through the Healthcare Marketplace, your employer, Medicare, or Medicaid, then your insurance most likely covers all medically necessary types of addiction treatment.
- Detox programs
- Residential or inpatient programs
- Medication-assisted treatment programs
The amount of coverage can be full or partial, so it’s important to check with Bedrock Recovery Center to verify your insurance coverage.
If you have a flexible insurance plan and you’re using a covered out-of-network provider, you’ll most likely receive partial coverage even if your plan typically covers services fully.
The only insurance policies that do not cover addiction treatment as a pre-existing condition include:
- Grandfathered plans, or insurance plans that went into effect before the Affordable Care Act and haven’t changed meaningfully since then
- Short-term plans, which can include vacation plans, travel plans, plans meant to cover a lapse in insurance, and emergency coverage plans
If you have a grandfathered plan or any type of short-term plan, your insurance company most likely will not cover drug rehab treatment.
How to Check Which Types of Treatment Your Insurance Plan Covers
If you’re having trouble finding details about the types of treatment your insurer will cover, you can:
- Call Bedrock Recovery Center to verify your insurance plan.
- Call Member Services for your insurance company by locating the phone number on your Member ID card
- Log in to your insurer’s online portal to find self-service details about your plan and policy
Confirm Your Insurance Coverage With Bedrock Recovery Center
If you’re thinking about recovering in scenic Massachusetts, Bedrock Recovery Center can help you check which treatment programs are covered.
Our admissions team will contact your insurer and get the details, including the extent of your insurance coverage and any out-of-pocket costs.
Contact us today to schedule a call and find out if our evidence-based addiction programs are a match—with both you and your insurer!