Understanding Insurance & Substance Abuse Treatment

With most insurance plans, there will be a selection of doctors and facilities that are in-network for you to choose from. Out-of-network options are typically either covered at a lower rate or not covered.

Does Insurance Help With the Cost of Substance Abuse Treatment?

Insurance can help with the cost of substance abuse treatment. It is typically how an individual can afford rehab and residential treatment, which can be expensive if paid completely out of pocket. While the specifics vary between individual providers and plans, most modern health insurance plans will cover mental health services, of which substance abuse treatment qualifies. 

In fact, plans that aren’t able to cover substance abuse treatments typically won’t count as qualifying health coverage, which is coverage that meets the standards set by the Affordable Care Act. Plans that don’t meet this standard are available, but they aren’t generally recommended unless a person has specific needs that these plans may help them meet, such as using them to supplement a different insurance plan. 

Overall, the ACA dramatically improved the availability of substance abuse treatment coverage, in part to help combat the opioid epidemic. 

What Does Insurance Typically Cover for Substance Abuse Treatment?

Assuming one’s plan counts as qualifying health coverage, a plan typically covers treatment for a substance use disorder (SUD) that would be considered appropriate by a medical expert and for which a cheaper alternative does not exist. 

Even if a cheaper alternative does exist, the plan still may or may not cover the treatment, depending on the specific circumstances causing a person to seek the more expensive treatment. In some cases, the less expensive treatment may need to be attempted first. 

Depending on a person’s policy, there will generally be specific facilities and doctors they either have to use or that will provide the best pricing (with exceptions usually existing in cases of emergency).

Some costs a person can usually expect a plan to cover include those associated with the following:

• Condition diagnosis 
• Prescription medication
• Counseling
• Hospitalization
• Lab services
• Short-term inpatient stays (rehab)
• Long-term residential stays

Types of Insurance Plans That Cover Substance Abuse Treatment

There are many types of insurance plans available. Typically a plan is rated by metal levels, which go from Bronze to Silver to Gold and then Platinum. This metal level reflects how much a person will generally spend out of pocket, which we discuss in more depth later. 

These are common plan types:

Preferred Provider Organization (PPO)

One of the more popular styles of plans, a PPO allows a person to choose between using services within the plan’s network or outside that network. 

Doctors and treatments at facilities outside the network still get covered by the plan, but you receive less coverage than if you choose an in-network option. You may be able to go out-of-network and still get the same coverage with a referral, depending on the situation.

Preferred Provider Organization (POS)

Somewhat similar to a PPO, this type of plan also allows you to choose between going in-network or out-of-network, with in-network treatment usually being less expensive. With a POS-style plan, an individual usually needs referrals before they can see specialists.

Exclusive Provider Organization (EPO)

This is a type of plan where, barring emergencies, a person must get treated at a “preferred provider,” which is a treatment provider that is within the insurance provider’s network. 

Health Maintenance Organization (HMO)

This type of plan shares many similarities with EPO-style plans. A person can generally only receive care from in-network doctors who either work for or contract with the HMO. You may also have to live in a particular area, or work in that area, in order to be covered under this type of plan.

Out-of-Pocket Costs

The specific costs you end up paying for a given treatment depend on a number of factors. One of the most important is the metal level of your plan, which works as a quick way to understand the amount of coverage you can expect, at least when choosing an in-network option. 

As noted by HealthCare.gov, you can expect to pay the following of your treatment’s total cost, depending on the level of your plan:

• Bronze: 40% of costs
• Silver: 30% of costs
• Gold: 20% of costs
• Platinum: 10% of costs

Other factors to consider are your monthly premiums, which tend to be higher as your coverage increases, and your deductibles, which can be much higher for plans with lower monthly premiums. 

The best plan in terms of keeping your costs low will depend on the type of treatment that best suits you. A higher tier plan can be of significant benefit to people who may need more expensive kinds of substance abuse treatment, such as those who may need to enter a residential treatment program. 

When selecting a plan, consider that treating a substance abuse problem is typically a long-term process. Your plan will also cover medical costs beyond those associated with substance abuse treatment, so it can serve multiple purposes depending on your overall medical needs.

Getting Insurance to Cover Rehab

If you want to get your insurance company to cover rehab, try to find a facility that is in-network. Because of the costs involved, talk to the facility you’re considering and work with them to maximize your coverage. Getting a definitive diagnosis of SUD or a condition that otherwise justifies rehab is often an important part of this process.

If you have problems getting coverage, talk with the treatment professionals who recommended rehab and also research your insurance company’s appeal process. In some cases, you may need to work with a treatment professional to present a valid, medical argument as to why rehab is an important part of your recovery process. 

Tips to Afford Substance Abuse Treatment if You Don’t Have Insurance

If you don’t have insurance, we recommend you visit HealthCare.gov and search through their plans. 

In many cases, individuals who feel they can’t afford health insurance can actually automatically save on their monthly premiums up to a certain amount based on the state they live in, the number of people in the household, and how much the household makes each year. Many people who would struggle to pay the listed monthly premium on a health insurance plan are at an income level where at least some plans won’t cost them anything each month or would cost a small amount (under $50) each month.

It’s worth calculating your expected medical costs for the year if you don’t have insurance, as you may end up saving money by getting insurance. While it isn’t always intuitive, sometimes paying a monthly premium for a health insurance plan can end up getting you coverage that reduces your medical costs enough that you save more than you spend in the year. This is frequently the case for people who have significant medical costs in that same year, such as those who might need rehab or residential treatment.

You may qualify for Medicare or Medicaid. Visit HealthCare.gov to see if you do.

You can also access government resources, such as the governing substance abuse agency in your state. These entities host state-funded addiction treatment. You can contact them to see if you qualify.

Many treatment facilities will work with you if you are unable to afford treatment. Some offer payment plans where you can finance the cost of care. You’ll then pay off the bill on a monthly basis at a manageable rate once you are stable in recovery.

Helpful Resources 

• HealthCare.gov: This government resource is meant to streamline the health insurance process and make it easy for you to get covered. You can use the site to access a large pool of useful, straightforward resources explaining different aspects of the insurance process.
  
  It also is set up so you can input your information and sign up for one of the many health insurance plans available to you. The plans are listed in an easy-to-understand format that makes comparing options fairly simple.
  
• SAMHSA’s National Helpline: For people struggling with addiction or who have someone in their life who might be struggling, this helpline can be a good resource to start the path to recovery. SAMHSA is the Substance Abuse and Mental Health Services Administration, a government administration designed to help people get treatment for substance abuse and mental health problems.
  
  The helpline, available at 1-800-662-HELP (4357) in both English and Spanish, is a free and confidential information service meant to direct people toward the information they need in order to get access to treatment. The line can help you learn about local treatment facilities, support groups, and more.