Anthem Insurance Coverage for Drug & Alcohol Treatment

Does Anthem Cover Addiction & Drug Abuse Treatments?

Because of the Affordable Care Act (ACA), insurance companies are required to provide at least some addiction treatment coverage. States can also impose further requirements. 

Anthem plans can cover most of the services associated with addiction treatment, including these:

• Detox treatment
• Inpatient or residential treatment
• Outpatient therapy and counseling

Verifying Coverage for Addiction Treatment

Anthem offers tools to check if a provider is in their network. While your plan may allow you to see providers outside their network, costs will generally be lower if you stay in-network for your treatment. 

To make sure you are covered, you can contact the treatment center and discuss your concerns. Most treatment centers are willing to help clients check their coverage. You can also contact Anthem directly and ask about a particular treatment option you’re considering in order to confirm your coverage level.

The Typical Cost of Treatment

The average cost of drug treatment is highly dependent on the type of treatment received and your insurance coverage. For example, one source estimated outpatient treatment for cocaine or heroin was about $3,100 per year. Residential treatment for cocaine use was estimated to be about $12,500 per year. At some facilities, inpatient treatment can cost tens of thousands of dollars per month.

Assuming a client is using an in-network provider with a Silver-tiered Anthem plan (discussed more in the next section), 70 percent of their costs would be covered once they met their deductible. Based on the above estimates, that would mean outpatient treatment would cost the individual $930 per year, and residential treatment would cost $3,750 per year. There would also be smaller additional costs, such as their monthly insurance premium.

Relevant Plans

Anthem offers three types of plans that will determine what treatment options make sense for you.

Health Maintenance Organization (HMO)

Unless it’s a medical emergency, HMOs generally don’t allow you to see doctors outside your network. You will also often need referrals to see in-network specialists. However, HMOs also usually offer the lowest premiums, and Anthem does have in-network addiction treatment providers. 

Preferred Provider Organization (PPO)

A plan of this type offers more versatility than an HMO, allowing you to see providers outside of the preferred network but at a higher (but still partially covered) cost. You also don’t need referrals to see specialists. 

Exclusive Provider Organization (EPO)

EPOs blend some of the positive traits of both HMOs and PPOs. You don’t need referrals to see specialists with an EPO, and your premiums will generally be lower than with PPOs. However, you still cannot generally get coverage for out-of-network providers.

Plan Coverage Categories

Another element of plans is their metal rating. Anthem plans are rated as one of four metals: Bronze, Silver, Gold, and Platinum. A higher tier of metal usually signals a higher monthly cost but also greater coverage of your healthcare costs. 

The minimum amount of coverage is as follows, but note that you will likely still need to first meet your deductible before getting coverage:

• Bronze: 60% of costs
• Silver: 70% of costs
• Gold: 80% of costs
• Platinum: 90% of costs

In-Network vs. Out-of-Network Coverage

Anthem is available in 14 states, including these:

• California
• Colorado
• Connecticut
• Georgia
• Indiana
• Kentucky
• Maine
• Missouri
• Nevada
• New Hampshire
• New York
• Ohio
• Virginia
• Wisconsin

Anthem’s network is fairly extensive, covering 1.7 million doctors and hospitals nationwide. Addiction treatment from providers within this network will allow you to take full advantage of your plan. 

As touched on in the previous section, your ability to use out-of-network providers is more limited. Depending on your plan, you may need to pay the full cost of any out-of-network treatments, and you will almost always have to pay more than if you used an in-network provider regardless of plan.

Length of Treatment Covered

Anthem will typically cover the cost of treatment for its duration, as long as it is evidence-based and otherwise would have been covered. Note that you may run into problems if a cheaper treatment option is also available that would be considered equally as effective in treating your addiction, but this isn’t typical when using traditional treatment options. 

Covering Out-of-Pocket Costs

If your out-of-pocket treatment costs may be higher than you can immediately afford, you have a few options you can consider to help you cover the costs. 

Two options are health savings accounts (HSAs) and flexible spending accounts (FSAs). These are two options that can help you reduce the cost of your treatment through tax savings. These are pre-tax accounts, meaning the money contributed to them is not counted for the purpose of taxation, sometimes allowing for savings as high as 30 cents on the dollar. 

You also can consider financing your medical costs. Many treatment providers offer a system to help finance treatment costs, and some third-party companies can also offer loans to cover medical costs at what are often fairly reasonable rates. With financing, you pay off the total cost of treatment over time at a manageable monthly rate versus paying the lump sum up front.