Does Insurance Cover Outpatient Rehab Treatment?
It’s normal to have a lot of questions, since outpatient rehab insurance coverage can be hard to navigate.
The good news is, many health insurance plans do cover outpatient rehab treatment. That’s because of the Affordable Care Act of 2010. All long-term insurance plans must cover outpatient rehab treatment as a medically necessary treatment as long as you have a pre-existing condition (e.g. substance use disorder).
There are a few exceptions—your insurance may not cover outpatient rehab if:
- Your policy started before 2010 and it hasn’t changed since then, or
- Your policy includes short-term coverage, including emergency, travel, or gap coverage plans
Luckily, the vast majority of healthcare plans are subject to the Affordable Care Act, so they must cover outpatient rehab under the right conditions.
Outpatient drug rehab insurance coverage can be full or partial. With full coverage, you pay nothing for your outpatient treatment except the deductible. If your coverage is partial, then you might owe a copay or another form of financial responsibility.
If you stopped following at deductible, there are a few basics you should know about how drug rehab insurance works. The more you know, the better you can prepare before your recovery starts.
What Are the Factors Influencing Outpatient Rehab Program Costs and Insurance Coverage?
There are many factors that affect outpatient rehab costs and coverage. The factors that affect the listed cost of rehab include:
- The location: If you live (or commute) and attend rehab in a metropolitan area, it can be more expensive compared to rural outpatient rehab.
- The program: Intensive outpatient programs are more expensive than programs that you attend for only a few hours per week.
- The treatments offered: The number and types of treatments included in a program (e.g. cognitive-behavioral therapy, motivational interviewing, medication-assisted treatment) affect its cost.
- The staff: Outpatient rehabs that have high-profile, experienced addiction specialists on staff may cost more. The same is true of rehabs that staff full addiction care teams, including nurses, aides, therapists, counselors, and doctors.
Just like the cost of rehab can fluctuate, so does rehab health insurance coverage. Some people pay nothing for outpatient treatment, while others pay a copay for prescriptions and appointments.
The factors that affect your outpatient rehab coverage include:
- Medical necessity: Your insurance company will want to know that your outpatient treatment is medically necessary. That means seeing your family doctor for a substance use disorder diagnosis and a referral to outpatient rehab.
- The facility: Any rehab facility must be approved by your insurance company before you can get outpatient rehab insurance coverage. Choosing a rehab that your insurer doesn’t recognize can lead to your coverage being denied.
- The program: Your insurance plan may cover different programs to different degrees. For instance, a partial hospitalization outpatient program may have a higher out-of-pocket cost than a standard outpatient program.
- The type of policy: Each type of healthcare policy has its own regulations around outpatient treatment coverage. They include Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Point-of-Service (POS), and Employer Group plans.
- Provider networks: Some healthcare plans require that you choose an outpatient provider that’s in-network. Others allow you to go out-of-network but your out-of-pocket cost will be higher.
Understanding Outpatient Rehab Coverage
Outpatient rehab insurance works the same way other treatment insurance coverage does. The process includes:
- Contacting your insurance company to let them know that you plan to use your outpatient rehab insurance coverage.
- Seeing your family doctor to establish that you have a substance use disorder and that outpatient rehab is necessary.
- Getting a referral to treatment that can come from your family doctor or behavioral health specialist.
- Reaching out to your outpatient rehab to confirm that they accept your coverage—the admissions team will check with your insurer to confirm your financial responsibility, if any.
Unlike inpatient rehab, outpatient rehab usually does not need a prior authorization. That process is typically for hospital stays or high-cost treatment.
How Much Does Insurance Pay for Outpatient Rehab?
The actual amount that your rehab insurance covers for outpatient rehab is hard to predict because it can vary so much.
For instance, if your plan covers 100% of treatment and you’ve already met your deductible, your cost for outpatient rehab is nothing. But the next person’s insurance could offer partial coverage, leaving them to pay a copay for appointments and prescriptions.
You can learn how much your rehab insurance coverage pays for outpatient rehab by contacting your insurer. Your Member ID card has a phone number on it, which you can use to contact Member Services and confirm your outpatient rehab coverage.
Other ways to find out how much your insurance pays include:
- Asking your doctor: If your primary care or behavioral health doctor is referring you to outpatient treatment, ask them to check your insurance coverage too.
- Checking your insurer’s website: Your insurance company has a website that includes a members-only portal that you can use to check your coverage.
- Contacting your outpatient treatment center: Most treatment centers are happy to confirm your insurance coverage by reaching out to your insurer on your behalf.
How Long Does Insurance Cover Outpatient Rehab?
The length of outpatient rehab coverage varies depending on your policy and the program costs.
If your insurance company bills outpatient rehab as its own type of rehabilitation visit (like physical therapy or post-surgical PT), then the number of days could be capped at 30, 60, 90, or somewhere in between.
Some insurance companies bill outpatient rehab services all separately. That means individual charges and copays for appointments, prescriptions, lab services, and behavioral health sessions. In that case, your outpatient days may not be limited at all.
How to Cover Outpatient Rehab When Insurance Won’t
If you have a grandfathered plan, a pre-2010 plan, or a short-term insurance plan, then you’re probably dismayed to learn that your insurance won’t cover outpatient rehab. The same is true if you don’t have insurance coverage.
The good news is, you can cover rehab without insurance. There are local and national resources to tap for help with outpatient rehab.
Here’s where to start:
- Your local recovery community, who can direct you to local resources
- Free rehab scholarships such as 10,000 Beds
- Your local social services office, who can refer you to government services for addiction help
Verifying Coverage and Finding the Best Outpatient Rehab Services
You should always verify your insurance coverage before you start the admissions process. In fact, verify your outpatient rehab insurance coverage as soon as you know that you need to use it.
There are a few easy ways to verify insurance coverage:
- Ask your family doctor or specialist: Your medical care team already has your insurance information. They can help you start the process by verifying coverage at the point of referral.
- Call your insurance company: Check your insurance card for a phone number you can use to contact Member Services. You should be able to reach the customer care team who can confirm your outpatient coverage.
- Check the online portal: Your insurance company has an online portal where you can log in and check details for your specific plan and its coverage.
- Call your outpatient rehab: Outpatient rehabs have admissions teams that are happy to check your insurance coverage for you.
If you’ve verified your coverage but don’t have an outpatient rehab in mind, then you have a few options:
- Ask your insurance company for a list of covered outpatient rehabs
- Check local outpatient rehabs near you
- Ask your family doctor or behavioral health doctor for a referral to a recommended treatment center
Your insurance company and your doctor are the best sources of information about outpatient rehab. If you’re part of the recovery community in your area, they may be able to help with sourcing the best outpatient rehab options as well.
What Substances Does My Health Insurance Cover for Outpatient Rehab?
As long as it’s a long-term health plan, your insurance company will cover outpatient rehab for any substance as long as you meet the criteria for a substance use disorder.
That generally means that the substance must be addictive or dependence-causing to warrant outpatient rehab coverage.
Is Alcohol Outpatient Rehab Covered By Health Insurance?
Alcohol outpatient rehab is covered under your health insurance plan as a medically necessary treatment for alcohol use disorder.
Most alcohol rehab insurance covers:
- Alcohol partial hospitalization programs: PHP is the highest level of outpatient care for alcohol addiction with a full-time attendance commitment.
- Alcohol intensive outpatient programs: IOP is a part-time outpatient program that provides intensive care, but with shorter day sessions.
- Alcohol outpatient programs: Standard outpatient programs treat alcohol addiction on your schedule so you can keep working, going to school, or caring for your kids.
- Alcohol medication-assisted treatment programs: Medication-assisted treatment (MAT) uses prescription medications to reduce the long-term effects of alcohol withdrawal.
Is Cocaine Outpatient Rehab Covered By Health Insurance?
Outpatient rehab for cocaine addiction is always covered for people who have a stimulant use disorder. The covered services for outpatient rehab include:
- Appointments, including routine care, follow-ups, and MAT appointments
- Behavioral treatment such as motivational interviewing, cognitive-behavioral therapy, or internal family systems therapy
- Group support such as group therapy, recovery groups, or group counseling
- Lab services, including urinalysis and bloodwork
Your cocaine rehab insurance covers these services as part of partial hospitalization, intensive outpatient, or standard outpatient programs.
Medication-assisted treatment insurance coverage is not included for cocaine addiction since it’s not medically proven or evidence-based for drugs other than opioids and alcohol. Insurance companies only cover treatment that has a proven track record for addiction.
Is Heroin Outpatient Rehab Covered By Health Insurance?
Heroin outpatient rehab is covered by health insurance for people who have opioid use disorder, and heroin addiction counts. Your insurance might cover these outpatient rehab programs for heroin:
- Full-time partial hospitalization for heroin
- Part-time intensive outpatient for heroin
- Standard outpatient programs for heroin
Within those programs, heroin rehab insurance covers:
- Appointments
- Dual diagnosis treatment
- Prescription medication
- Counseling
- Therapy
Is Meth Outpatient Rehab Covered By Health Insurance?
Your outpatient rehab insurance coverage most likely includes meth addiction treatment. If your doctor diagnoses you with stimulant use disorder, then that’s enough to justify coverage.
Your meth rehab insurance coverage includes:
- Partial hospitalization: This intensive program for meth treatment requires 8 hours a day of care, but you can go home and sleep in your own bed between sessions.
- Intensive outpatient: With an IOP for meth, you’ll attend half-sessions and they might not be every day. You have more time at home with an IOP.
- Standard outpatient: Most outpatient programs for meth are part-time and flexible around your schedule and needs.
Is Prescription Drug Outpatient Rehab Covered By Health Insurance?
Your insurance company covers prescription drug outpatient rehab as long as the prescription drug in question is addictive or dependence-causing.
Your insurance company needs to know that you have a substance use disorder or prescription drug addiction so they can decide to cover outpatient rehab.
Most prescription drug rehab insurance covers the following:
- Appointments for routine care, follow-ups, and medication
- Counseling sessions for personal reflection and growth in recovery
- Group support such as 12 Steps, recovery support groups, or therapy groups
- Lab services including blood work and urinalysis
- Prescription medication for medication-assisted treatment
- Recovery workshops to teach lifelong skills for coping with substance use disorders
- Therapy sessions in disciplines like cognitive-behavioral therapy, dialectical behavior therapy, or psychoanalysis
Why Bedrock Recovery Center?
If you have health insurance that covers substance abuse, the admissions team at Bedrock Recovery Center is ready to verify it for you.
You don’t have to tear your hair out searching for the answer to “does insurance cover drug rehab?” when it’s right here. Call Bedrock Recovery Center to confirm your rehab insurance coverage right now!
Sources
- Affordable Care Act (ACA) – HealthCare.gov Glossary
- Inpatient and Outpatient Treatment for Substance Use Disorder
- Outpatient Services In Hospitals Coverage
- Medicare and Substance Abuse Treatment: What Is Covered?
- What are the treatments for heroin use disorder?
- Stimulant-Related Disorders
- How can prescription drug addiction be treated?
- Treatment for Alcohol Problems: Finding and Getting Help
