*Insurance Disclaimer: Greenbranch Recovery will attempt to verify your health insurance benefits and/or necessary authorizations on your behalf. Please note, this is only a quote of benefits and/or authorization. We cannot guarantee payment or verification eligibility as conveyed by your health insurance provider will be accurate and complete. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service. Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” Greenbranch Recovery will make every effort to have all services preauthorized by your health insurance company. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under your plan, your insurer will deny payment for that service and it will become your responsibility.
Many people choosing to enter rehab for addiction may have wondered whether or not certain services are covered by health insurance, and in general, the answer is yes — many health insurance plans cover treatment and rehab services for alcohol and drug addiction.
Is Addiction Treatment Covered?
Under federal law, most private insurance plans and all government insurance plans must provide coverage for drug and alcohol addiction treatment. But that doesn’t necessarily mean every treatment program will be covered under your plan or that your healthcare plan will pick up the tab for treatment 100%. Here’s what you need to know to find the answer to the question “Does insurance cover rehab?”
Updates to Addiction Recovery Coverage
The ‘No Surprise Act’ has gone into effect as of January 1st, 2022. It prevents out-of-network care providers from billing clients more than the specified in-network cost-sharing amounts, which are based on a ‘recognized amount’ (specified by state law, or for those that have an all-payer model agreement, approved by the state). You can learn more about the law at cms.gov/nosurprises.
Understanding Behavioral Health and Addiction Insurance Coverage
Under the Affordable Care Act, health insurance policies sold through the marketplaces, along with Medicare and Medicaid, must all provide benefits for behavioral health care, which includes addiction treatment. That means if you have any of those types of insurance plans, you have some type of coverage that will help pay for these services.
Patients are responsible for paying the deductible on the policy and any other out-of-pocket costs not covered by their insurance carrier. If you have coverage for these types of treatment services under your healthcare plan, the total amount insurance will cover depends on a number of factors.
Many healthcare plans operate on network systems. They require providers — the people and treatment facilities that provide drug addiction services — to apply to be in-network with them. When you are treated by an in-network provider, the insurer foots more of the bill than when you are treated by an out-of-network provider.
Deductibles, Copays and Coinsurance Amounts
Other factors that determine how much your policy helps pay for drug rehab — and how much you may need to pay — are deductibles and copays. Most healthcare plans require you to share some of the cost of rehab. That’s managed through these factors.
Your deductible is how much of your total care each year you have to pay for before your policy starts to cover things. Luckily, you probably only have one deductible. That means if you have used your insurance benefits for anything — from routine physicals to ER visits to a hospital stay — those charges have added up to count toward your deductible.
Here’s a scenario to help you understand:
- Sue has a policy with a $3,000 deductible.
- She has been to the ER once and paid $700 in services. She has had three doctor’s appointments for a total of $600 in charges, and she has $200 in medication charges. That’s a total of $1,500 toward her deductible.
- She has $1,500 left on her deductible. If Sue seeks addiction recovery services, she would be responsible for the first $1,500 in charges before her policy started to pay on claims.
Copay and coinsurance amounts are the totals you pay for outpatient or inpatient rehab after you meet your deductible. This is different for every plan. Some policies frame copays as percentages, such as 10% of inpatient charges. Others set a specific number, such as $500 for each stay.
Preauthorization’s and Referrals
Depending on your healthcare plan, a preauthorization or referral — or both — may be required to ensure the insurer will pay claims for services.
A referral occurs when your primary care physician provides a referral for you to seek other services. This can occur in several ways. Sometimes the physician writes a prescription for the other services. Other times, they may simply call ahead to the facility to arrange an appointment so you can seek consultation for addiction treatment. In these cases, the physician’s office and rehab center work together to ensure the referral is documented appropriately.
A preauthorization occurs when the treatment center gets approval from the insurer to provide services before you enter an addiction treatment program. If your provider requires a preauth, this step is necessary. Otherwise, your provider may deny any claims for services provided.
The Importance of Insurance Verification
“Does insurance cover rehab?” is actually a complex question, as you can see from the information above. But professional drug treatment centers are used to dealing with these details, and they can help you navigate policy issues.
In fact, most providers, including Greenbranch Recovery, know that conducting an insurance verification is a critical first step when someone is seeking substance abuse programs for addiction. A verification involves a provider calling your carrier to verify:
- That your coverage is currently in effect
- That the provider is able to bill for services under your plan
- Whether or not the provider is in-network
- What your deductible and copay amounts are
- Whether a preauth or referral is needed