Aetna Insurance Coverage for Drug & Alcohol Treatment

Does Aetna Cover Addiction and Drug Misuse Treatments?

The Affordable Care Act (ACA) requires private insurance providers to have some level of substance use disorder (SUD) treatment coverage, and states can also add additional requirements. Aetna plans will cover the majority of evidence-based treatments for addiction issues from in-network providers. 

Aetna also encourages addiction screening, brief intervention, and addiction treatment referrals. This practice, called SBIRT (screening, brief intervention, and referral to treatment) is evidence-based and aims to intervene in a person’s struggles with addiction or behavior that may develop into addiction as early as possible.

Verifying Coverage for Addiction Treatment

To verify your coverage, first read through your plan’s explanation of benefits and any additional information available on Aetna’s site relevant to the costs you want covered. Then, find an in-network treatment provider that can provide the addiction treatment you need.

Talk with the treatment provider you’ve selected about their insurance verification process and what information they need from you. In some cases, you may also need to talk directly with Aetna about the coverage they can provide for a given treatment option. 

The Typical Cost of Treatment

The typical cost of addiction treatment can vary greatly. One estimate gives outpatient care a yearly cost of about $3,000 and places inpatient care at about $12,000 per year before accounting for insurance coverage. Luxury treatments can cost significantly more, sometimes approaching $100,000 or more annually, and they are unlikely to be covered by insurance. 

Once you’ve met your deductible, an insurance plan will typically cover somewhere between 60 to 90 percent of your treatment costs. You may also reach your maximum out-of-pocket expense during your treatment, at which point all the remaining costs associated with your treatment may be covered for the year. 

When possible, it is usually best to calculate the costs and benefits a given plan will provide before selecting a plan, as this will maximize your savings. However, addiction treatment is admittedly often something that is not easily planned for.

Understanding Plan Options

Every insurance plan comes with an explanation of benefits, which is a document detailing everything the plan offers. These are some important factors to consider when selecting a plan:

Premiums

A plan’s premiums are the regular payments you make to keep your plan active. These payments are usually made on a monthly basis.

Deductible

A plan’s deductible is how much your total relevant medical costs have to have reached in the year for your plan’s full coverage to kick in. Plans with higher deductibles generally have lower premiums and vice versa. 

Coinsurance

Coinsurance is one of the most important parts of any health insurance plan. This is the percentage of medical costs you will pay once you meet your deductible. For example, a coinsurance rate of 20 percent means that you will pay 20 percent of most medical bills for costs within your network. 

Copays

Copays are flat fees associated with certain medical costs, such as doctor visits. One example Aetna gives is that an individual might pay $30 for regular doctor visits, $50 for seeing specialists, and $150 for a night in an emergency room.

Maximum Out-of-Pocket Expense

This is the maximum amount of money you will have to pay for relevant medical costs in a given year. Once your total medical costs (not just addiction treatment costs) reach this amount, you will no longer have to worry about any deductibles, coinsurance, or copays associated with your plan (although you typically would already have met your deductible). 

In-Network vs. Out-of-Network Coverage

Aetna plans are most beneficial if you go with in-network treatment providers. You can search for these providers using the search tool on their site. If you want to take full advantage of your plan, it is best to use treatment options within your network.

Out-of-network cost coverage will vary depending on the specifics of your plan. Some plans will have you pay the full cost of using out-of-network providers, barring certain emergency treatments. Many will cover some of the costs of out-of-network providers, but at a higher cost than if you stayed in-network.

Length of Treatment Covered

The entire length of your addiction treatment should typically be covered as long as you’re using evidence-based treatments and going with an in-network treatment provider. 

While longer treatment courses can be more expensive, especially residential treatment, using these treatment options will typically mean you also meet any deductible associated with your plan fairly early. You will also likely hit your maximum out-of-pocket costs at some point during your treatment as well. 

Covering Out-of-Pocket Costs

There are several ways to potentially cover the out-of-pocket costs associated with addiction treatment (and any other medical treatment). These are some potential options:

• Getting loans from family and friends
• Researching and selecting the best financing options you qualify for from both third-party companies and treatment providers
• Using HSAs or FSAs to receive tax benefits that can help reduce the burden of medical costs