Does Insurance Cover Medication-Assisted Treatment (MAT)
Medication-assisted treatment is a highly effective evidence-based solution for certain people. However, it’s an ongoing or maintenance therapy, which means that it’s a long-term, recurring cost.
There are a number of medications used in MAT. Although they’re all available as generics, it’s important to know whether your insurance policy covers them.
Additionally, most medication-assisted treatment programs include multiple sub-programs.
For instance, nearly every MAT program includes therapy or behavioral treatment. You may have questions about the way this works for drug rehab insurance coverage, e.g. whether they’re billed separately or together.
There’s good news: The Affordable Care Act of 2010 requires all long-term insurance policies to cover medically-necessary care for pre-existing conditions, including substance use disorder.
If your doctor can certify that MAT is medically necessary for your condition, then rehab health insurance will cover it, as long as the ACA applies to your plan.
You may have questions about your plan, such as:
- Does my rehab insurance policy cover MAT?
- What MAT medications are covered?
- What behavioral therapies are covered?
- Are appointments and med-checks covered?
- If my insurance covers MAT, does that mean I don’t have to pay anything?
- Is the intake visit covered?
It’s important to start answering your questions as soon as you’re thinking about recovery. You don’t want to figure out these answers when you’re supposed to be focusing on getting better.
Luckily, it’s not hard to navigate your insurance coverage. Even if you’ve never looked at your policy, you can get answers about your medication-assisted treatment coverage in the amount of time it takes to make a phone call.
Understanding Medication-Assisted Treatment Coverage
Insurance coverage for medication-assisted treatment works the same way as any other coverage.
When you and your doctor decide that it’s time for you to get treatment, the process includes:
- Confirming coverage
- Getting a referral
- Completing prior authorization (if necessary)
- Receiving approval for coverage
What to Expect
Just like your primary care doctor handles billing and claims in their office, your addiction care provider will most likely handle the process for you.
- Reach out to your insurance company to confirm the coverage on your policy
- Handle prior authorization including any paperwork and phone calls
- Confirm the details of your coverage, including the amount you’re responsible for paying
Your role is to find out what’s covered, ask your primary care doctor for a referral, and learn what to expect from the rest of the process. Your treatment provider will work on the rest with your insurance company.
When your insurer approves medication-assisted treatment insurance coverage you’ll receive a statement of financial responsibility that details:
- The cost of treatment
- The amount of treatment covered by your policy
- The amount that you’re responsible for covering
You’ll also receive an explanation of benefits that explains how the coverage was applied, including which services are (and aren’t) covered. The explanation of benefits also includes:
- Whether your deductible was applied: The deductible is the cost you must cover for all healthcare before your coverage takes over. It resets once a year.
- Copays or coinsurance: A copay is a set amount that you contribute toward your treatment, while coinsurance is the remaining percentage of the cost after insurance pays their portion.
Most plans offer partial coverage for addiction treatment, including MAT; but some plans include full coverage.
If your plan has full coverage, you won’t have a copay or coinsurance, but you may be responsible for a deductible.
If your plan has partial coverage, you will be responsible for a copay or coinsurance and for meeting the deductible (if you didn’t already meet it earlier in the year with other healthcare).
Once you have confirmation of coverage, you can move ahead with medication-assisted treatment!
Which Services Are Covered?
Health insurance that covers substance abuse typically pays for any MAT services that are considered medically necessary.
That usually includes (but double-check with your insurer):
- Medication for alcohol use disorder, including acamprosate, disulfiram, and naltrexone
- Medication for opioid use disorder, including naltrexone, buprenorphine, and methadone
- Behavioral therapy, such as cognitive-behavioral therapy or dialectical behavior therapy
- Blood and urine tests to measure treatment progress
- Appointments to receive medication and follow-up, including daily checkups for patients new to MAT
These services make up the majority of MAT programs, and they’re usually included in your insurance coverage.
Whether they’re covered fully or partially depends on your insurance plan and policy.
Always check with your insurance company to get the full details of your specific plan’s coverage for MAT services.
There are some plans that may not pay for MAT services (though they’re uncommon), including grandfathered plans from before 2010 and short-term emergency plans.
What Factors Influence Medication-Assisted Treatment Program Costs and Coverage?
Even though most plans cover MAT, the exact costs and coverage can vary.
The factors that affect your coverage and cost include:
Cost of Treatment Program
Medication-assisted treatment programs can have differing base costs for services including:
- Behavioral treatment
- Lab testing
Your treatment center may bill these services together (as a program) or as separate services.
Separate billing often leads to a higher base cost. If your insurance company covers a percentage of each service (instead of a flat rate for a program), your responsible cost could be higher.
You won’t be responsible for the base costs with an ACA-compliant insurance plan, but the base costs could influence how much your out-of-pocket cost is.
PPO vs. HMO
The type of healthcare plan that you have can influence your end costs for MAT.
There are two main types of healthcare plans:
- Preferred Provider Organizations: A PPO has higher out-of-pocket costs, including deductibles, copays, and coinsurance.
- Health Maintenance Organizations: An HMO has affordable deductibles, copays, and coinsurance. Some services might be covered in full.
In- vs. Out-of-Network
Your insurance company may cover more or less of the cost depending on whether your treatment center is in- or out-of-network.
If you have an HMO, your insurance company won’t cover out-of-network providers at all. Your out-of-pocket cost is the base cost of treatment (but in-network providers are covered).
People with PPOs can choose out-of-network providers but may pay a higher copay or coinsurance cost.
How Much Does Insurance Pay for Medication-Assisted Treatment?
It’s hard to generalize how much insurance might pay for medication-assisted treatment. No two insurance policies are the same, and neither are any two treatment plans.
Some insurance plans pay for MAT in full, which means whatever the base cost of the treatment program, your insurance company will cover it. That means no financial responsibility on your part.
If you have an HMO, you’re more likely to have a plan that covers MAT (or some MAT services) in full. PPO plans always cover MAT, but it may be partial coverage.
However, there’s no standard for how much each company will pay for MAT.
The only way to know how much insurance will pay for MAT is to call the insurance company and check (or check online, or with your treatment center).
How Long Does Insurance Cover Medication-Assisted Treatment?
Generally, insurance companies cover medication-assisted treatment as long as it’s considered medically necessary.
Like asthma and heart disease, substance use disorder is a chronic condition that requires ongoing treatment.
Medication-assisted treatment especially works best with long-term adherence. The longer you keep going to MAT, the better your outcome can be.
In fact, many people make MAT part of their ongoing plan to stay in recovery, and keep attending for years.
You may need to visit your primary care doctor occasionally to establish that MAT is still necessary. Your insurance provider can let you know how often that’s necessary. It’s often an increment of a year, 6 months, or 3 months, but check with your insurer to be sure.
However, as long as you follow instructions to continue coverage, your insurance provider should continue to cover MAT as long as you need it.
How to Cover Medication-Assisted Treatment When Insurance Won’t
If you have a plan that’s not under the Affordable Care Act, you may be thinking fast to figure out how to cover the cost of treatment.
Those plans are rare—the majority of health insurance plans are long-term, so they are subject to the Affordable Care Act and must cover your treatment.
The only exceptions are:
- Plans that were active before 2010 when the ACA went into effect and have not undergone significant changes since then
- Short-term plans, which include emergency coverage, gap coverage, and travel coverage
Still, most long-term plans cover medication-assisted treatment on a partial basis, which means you’ll be responsible for a portion of the cost.
That cost could be in the form of a fixed copay or a coinsurance fee that scales with the cost of treatment and factors in the insurance company’s contribution.
Rehab without insurance (or with partial insurance) can be expensive, so you should have a plan.
If you’re thinking about how to cover the cost after insurance (or without insurance), your options include:
State and City Resources
Your local Social Services office can refer you to addiction treatment resources on the state and city level. Some of these resources may include help paying for treatment or getting low-cost treatment.
Rehab scholarships are no-strings-attached recovery grants from private organizations. The most famous rehab scholarship is 10,000 Beds, but there are many others.
The admittance process can be competitive with a long wait, so apply as soon as you think you’ll need help.
Your local community probably includes recovery havens like 12 Steps, Alcoholics Anonymous, Narcotics Anonymous, or other groups. Check with these communities to learn about resources that may not be public.
Churches and Religious Communities
If you’re part of a spiritual community like a church, a mosque, or a temple, check in to see what resources are available for members in recovery.
Even if you’re not part of the religion, give them a call, as long as the community is recovery-friendly.
Many communities set aside a Good Samaritan fund to help people outside the community who need assistance with basic needs, including medically-necessary treatment.
Verifying Coverage and Finding the Best Medication-Assisted Treatment Services
Now that you know what to expect from the entire insurance process, you can start verifying your coverage and deciding where to attend treatment.
There are a few ways you can verify your medication-assisted treatment insurance coverage:
Consult Primary Care
You’ll need to get a referral for treatment from your primary care doctor before attending MAT. When you do that, you can ask your doctor to confirm your insurance coverage for your referral.
Ask Your Treatment Provider
If you already know where you want to get your MAT, you can check with the treatment provider. They can confirm your coverage and let you know your financial responsibility.
Call Your Insurance Company
You can always call your insurance company directly to verify coverage for medication-assisted treatment. You can do that by calling the phone number on your insurance card.
Check the Self-Service Members Portal
Your insurance company has an online portal where members can log in and check policy information. Log in to the portal to find information about your MAT coverage.
What Substances Does My Health Insurance Cover for Medication-Assisted Treatment?
Most health insurance companies only cover MAT for alcohol- and opioid-related substance use disorders.
What Substances Aren’t Covered for Medication-Assisted Treatment?
Insurance companies only cover evidence-based, FDA-approved treatment, and MAT is not approved for any uses other than opioid and alcohol addiction.
If you have a different substance use disorder, call your insurance company to learn what treatments are covered.
Bedrock Recovery Center Can Help Cover and Start MAT
If you think medication-assisted treatment is right for you, Bedrock Recovery Center can help you get started in Canton, MA.
Call our Admissions Team at 855-602-7555 to get started verifying your coverage!
Bedrock Recovery Editorial Team
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This page does not provide medical advice.