Insurance Coverage for Addiction Treatment: What You Need to Know

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man calling insurance to inquire about coverage for addiction treatment

Finding insurance for substance use treatment may seem difficult, but luckily there are several options available. Whether it’s understanding your insurance policy, navigating the claims process, or finding a trusted treatment center that works with your insurance policy, we’ve got you covered. Don’t let the fear of financial burden hold you back from seeking the help you need. 

Does Health Insurance Cover Addiction Treatment?

The short answer is yes. The Affordable Care Act (ACA) lists drug or alcohol addiction care as 1 of 10 categories of essential health benefits, which means that any insurance sold on the Health Insurance Marketplace must cover addiction treatment. 

Rehab and addiction treatment can encompass a range of services, including detoxification, inpatient treatment, outpatient programs, counseling, and medication-assisted treatment which can add another layer of complexity.  

To determine your coverage, start by looking at your insurance policy for specific language regarding rehab and addiction treatment. Some policies may have a separate section dedicated to mental health and substance abuse coverage, while others may include it under general medical coverage. Pay attention to any limitations or exclusions, as these can impact your ability to receive coverage for certain types of treatment or at specific facilities. 

If you are unsure of where to begin, some addiction treatment centers, like Mountainside, have admissions specialists who will gladly help you verify your insurance. 

What Are the Different Types of Insurance Plans?

Health insurance coverage for rehab and addiction treatment can vary depending on the type of insurance plan you have. The most common types of insurance plans include employer-sponsored plans, individual plans, Medicaid, and Medicare. 

  • Employer-sponsored plans are offered by employers to their employees. These plans can vary in terms of coverage and may have options for you to seek care both in-network and out-of-network.  
  • Individual plans are purchased by individuals directly from insurance companies. These plans can also vary in terms of coverage and may have networks for you to seek care both in-network and out-of-network.  
  • Medicaid is a government-funded health insurance program that provides coverage to low-income individuals and families. Each state has its own Medicaid program, and coverage for rehab and addiction treatment can vary. Check your state’s Medicaid program to understand what services are covered and any requirements for accessing treatment. 
  • Medicare is a federal health insurance program for individuals aged 65 and older, as well as individuals with certain disabilities. Medicare coverage for rehab and addiction treatment can vary depending on the specific plan you have. It’s important to review your plan’s coverage to understand what services are included and any out-of-pocket costs you may be responsible for. 

MultiPlan Insurance Coverage for Rehab

MultiPlan is a facilitator of preferred provider organization (PPO) networks operating in select regions across the United States. PPOs are a health plan that has contracts with doctors, hospitals, and rehab facilities to create a network of providers for your individual needs. 

MultiPlan is not a company that offers insurance directly to members. Instead, clients can access MultiPlan well-being insurance through a health plan administrator or medical bill payer. With PPO healthcare insurance, you often have the option to partner with the provider of your choice without a referral.  

When it comes to addiction treatment, if you or a loved one has insurance that are members of the MultiPlan network, you could get coverage for detoxification and also inpatient treatment, medication management, and outpatient care. Look for an accredited treatment center like Mountainside which now accepts and is contracted with MultiPlan in an effort to erase financial treatment barriers and provide help to an even wider population.  

What to Look for in Your Insurance Policy for Addiction Treatment

With so many words and phrases related to insurance, it can be confusing to know what your policy actually covers. Below we break down some of the key factors to look out for: 

Coverage for different levels of care

Check that your policy covers a range of treatment options, including detoxification, inpatient treatment, outpatient programs, clinical therapy, and medication-assisted treatment. This will ensure that you have access to the appropriate level of care based on your individual needs. An easy way to determine this is to contact a trusted addiction treatment center, like Mountainside, to have their admissions specialists help you verify your insurance and coverage. 

In-network providers

An in-network provider is a health care provider that a plan contracts with to provide medical care to its members. These providers are called “network providers” or “in-network providers. 

Out-of-network providers

If you have a specific provider or treatment center in mind that is out-of-network with your insurance plan you may still be able to utilize your insurance to cover the cost pending you have out-of-network benefits.  

Co-pays and deductibles

Whether you are seeking treatment in-network or out-of-network, your cost will be dependent on your insurance policy’s co-pays and deductibles for rehab and addiction treatment. Consider your financial situation and determine how much you can afford to pay out-of-pocket. 

Limits and exclusions

Pay attention to any limitations or exclusions in the policy. These can include restrictions on the number of treatment sessions covered or specific requirements for pre-authorization or pre-certification. 

If anything seems unclear or you have questions about your healthcare plan, reach out to your insurance company directly to inquire about your coverage for rehab and addiction treatment. Whenever you’re speaking with your insurance company, you should document any conversations you have, including the date, time, and the name of the representative you spoke with. 

Other Options to Help You Cover Costs

Aside from insurance, some treatment providers such as Mountainside may have other routes for assisting with financial costs such as sliding scales or scholarships. Learn more about how you can pay for rehab here. 

Understanding the Pre-Authorization Process

Health insurance companies use pre-authorization to make sure that a specific medical procedure or treatment is needed and worth the cost. Pre-authorization is usually required for inpatient treatment, outpatient programs, and other services related to substance use treatment. To initiate this process, your treatment provider will submit a request to your insurance company, providing information about the recommended treatment, its duration, and the expected outcomes. The insurance company will look over the request and determine if the treatment meets their criteria for coverage. Unfortunately, pre-authorization does not always guarantee coverage, but it is a necessary step in the process. 

Although this time may be a bit stressful, the addiction treatment center will work with you and the insurance company to advocate for your needs.  

What Happens if Your Insurance Denies Coverage for Treatment?

If your insurance denies coverage for rehab and addiction treatment, don’t panic. There are steps you can take to appeal the decision and potentially secure the coverage you need. Here’s what you can do: 

  • Review the denial letter: Carefully read the denial letter from your insurance company. It should provide specific reasons for the denial and information on how to appeal the decision. Sometimes, there may be a simple error, which is a quick fix.  
  • Gather supporting documentation: Collect any supporting documentation that can strengthen your case. This may include medical records, and letters from your treatment provider explaining the medical necessity of the treatment. 
  • Submit a written appeal: Write a formal appeal letter to your insurance company, addressing the reasons for the denial and providing supporting documentation. Be clear, concise, and persuasive in your letter, emphasizing the medical necessity of the treatment and any extenuating circumstances that may impact your ability to access care. 
  • Seek legal assistance if needed: If your appeal is denied, you may want to consider seeking legal assistance. An attorney specializing in insurance law can help you navigate the appeals process and advocate for your rights. 

Additionally, you can consider reaching out to advocacy organizations or support groups that specialize in insurance coverage for rehab and addiction treatment. They will provide guidance and resources to help you get through the appeals process. 

At Mountainside, we complete the appeal process on your behalf so you can focus on your treatment. We exhaust every level of appeal based on your specific insurance policy’s appeal process.  

Seeking rehab and addiction treatment is a courageous step toward recovery, and having the right insurance coverage can make all the difference. By understanding your insurance policy, knowing the terms and definitions related to insurance coverage, advocating for yourself, and working with a trusted treatment center, you can navigate the insurance system with confidence. 

If you or a loved one is struggling with addiction, Mountainside can help.
Click here or call (888) 833-4676 to speak with one of our addiction treatment experts.