Does Insurance Cover Rehab?
Does insurance cover rehab? In short, yes. But not all insurance plans will cover all types of drug and alcohol rehabilitation.
Private insurance companies vary significantly in how much addiction treatment coverage they provide.
Public insurance programs, such as Medicare and Medicaid, provide coverage. But some types of coverage may have limits or requirements. Plans offered through the Health Insurance Marketplace as part of the Affordable Care Act, or Obamacare, cover mental health and substance abuse, though the specific benefits depend on the state and the health plan.
Someone seeking substance abuse treatment can ask a few in-depth questions such as:
- Do I have one or more forms of insurance coverage?
- Is my plan through a private insurance company or is it from a federal or state program?
- What type of treatment am I hoping to receive?
- Does my insurance cover the recommended treatment?
- Are there additional costs, fees, or charges required by the treatment provider or insurance company?
If you’re curious about the mental health and rehab coverage included in your insurance plan, call
1-888-968-9816 Who Answers? to learn more about plans and treatment providers that accept insurance as payment.
Private insurance plans are frequently provided by an employer to cover employees as well as their spouses and dependent children. Private insurance plans are created and maintained by companies including:
- Various Blue Cross and Blue Shield products.
In addition to these larger companies, many local and regional insurance companies offer coverage.
Many plans provide coverage for detoxification, inpatient, and outpatient rehab services.
- Your coverage will depend on what plan you have, who your insurance company is, and which state you live in.
- It can also depend on whether you see an in-network or out-of-network provider.
- Some plans may determine coverage on an individual basis. Others may put a limit on the number of days someone should be in treatment.
- Plans may require you to meet a deductible or dollar amount before coverage kicks in at a set percentage, or you will have to make a copay, or fixed amount of money charged for each appointment you attend or service you receive.
- Some plans may require an assessment before treatment can begin to determine if treatment is medically necessary. One type of evaluation called a SBIRT (Screening, Brief Intervention, and Referral to Treatment) can serve as a precertification. A medical provider determines your level of addiction and recommends an appropriate level of care.7
Medicare and Medicaid
Public insurance options such as Medicare and Medicaid are funded and controlled by the government on a federal, state, or county level.
Medicare is insurance for people:8
- 65 and older.
- Under 65 that have specific disabilities.
- With kidney failure.
Medicare is separated into 4 parts, including:8
- Part A – hospital insurance that covers inpatient care.
- Part B – medical insurances that cover outpatient care.
- Part C – a mix of part A and part B offered by private insurance companies that usually includes Part D.
- Part D – prescription drug coverage to help pay for medications.
Medicare will cover many drug abuse treatments such as:9
- Inpatient treatment.
- Outpatient treatments, including partial hospitalization programs that offer access to intensive treatment services.
- Medications for opioid dependence including buprenorphine (Suboxone) but not methadone.
Medicaid is public insurance managed by state and federal government aimed at covering people with low incomes (a percentage above the federal poverty level (FPL) based on your household size) and who are:8,10
- 65 and older.
- Under 19.
- Caring for a child.
- Adults without dependent children (in some states).
- Living with a disability.
Medicaid coverage can pay for:8,9
- Doctor appointments.
- Mental health/substance abuse care.
- Needed medications, including methadone.
Just like private insurance companies, Medicaid and Medicare may have copays and limits on the services covered. For example, Medicare only covers inpatient and outpatient rehab if the treatment is provided by a Medicare provider or facility, is deemed medically necessary, and a doctor establishes a treatment plan. 13 Medicaid coverage varies by state. Learn more about your state’s Medicaid coverage for substance abuse.
Some drug and alcohol recovery programs may not accept Medicare or Medicaid as payment.
Some people may qualify for both Medicare and Medicaid. These people with “dual-eligibility” will have very little out-of-pocket expenses.8 Cost differences will vary by plan and state where coverage is received. Determine if you qualify for Medicaid here.
Learn about specific eligibility, enrollment, and care for your state on the Medicaid website.
For more information on Medicare, call 1-800-MEDICARE or visit the Medicare website.
Affordable Care Act (Obamacare)
Often called “Obamacare,” the Affordable Care Act (ACA) works to insure more people with extended public and private coverage.11,12
Specific to mental health and addiction, the ACA increases access in 3 ways:11,12
- Increasing parity between physical health and mental health/substance use disorder coverage, meaning that both must be covered equally. The parity protections expand coverage to 62 million Americans that may not have had access to substance abuse treatment.
- Increasing preventative care. Many health plans must now pay for preventive mental health/substance use services such as free screenings and assessments to identify conditions.
- No denial of coverage based on pre-existing conditions. Health plans can no longer deny coverage based on pre-existing conditions or past history of addiction or substance dependence.
Along with expanding coverage and offering parity, the ACA gives individuals access to the Health Insurance Marketplace.
Along with expanding coverage and offering parity, the ACA gives individuals access to the Health Insurance Marketplace. The marketplace, available at HealthCare.gov, permits people to: 11
- Compare and explore available private insurance plans.
- Receive information about their Medicaid eligibility.
- Understand their health insurance choices.
- Identify available tax credits to help pay for insurance.
- Enroll in health insurance.
According to Healthcare.gov, all plans offered through the Health Insurance Marketplace must cover:
- Behavioral health treatment, such as therapy.
- Inpatient mental and behavioral health services.
- Treatment for substance abuse disorders.
The specific benefits depend on the plan and the state you live in. You can compare plans and find coverage on the Healthcare.gov site.
- Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings.
- National Institute on Drug Abuse. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide.
- National Insurance Markets. (2012). UPMC Health Plan: Summary of Benefits.
- Duquesne University. (2016). Highmark Blue Cross Blue Shield: PPOBlue.
- Aetna. (2016). Aetna Leap Basic: Summary of Benefits and Coverage.
- Substance Abuse and Mental Health Services Administration. (2015). Detoxification and Substance Abuse Treatment.
- Substance Abuse and Mental Health Services Administration. (n.d.). SBIRT: Screening, Brief Intervention, and Referral to Treatment.
- Centers for Medicare and Medicaid Services. (2015). What is Medicare?
- Centers for Medicare and Medicaid Services. (2015). Medicare Coverage of Substance Abuse Services.
- Centers for Medicare and Medicaid Services. (2014). Coverage and Delivery of Adult Substance Abuse Services in Medicaid Managed Care.
- U.S. Department of Health and Human Services. (n.d.). Health Insurance and Mental Health Services.
- The White House. (2016). Fact Sheet: The Affordable Care Act: Healthy Communities Six Years Later.
- Medicare Interactive. Medicare coverage of treatment for alcoholism and drug abuse.