Insurance Coverage of Alcoholism Treatment

Alcohol and substance abuse is a complex disorder that impacts nearly every area of a person’s life, including family life, social life, professional life, and more. Alcohol and substance abuse treatment can be delivered in a variety of settings and include several different components.

The components of Alcohol and substance abuse can be as singular and direct as addressing a person’s drug use alone or as complex as targeting each area of a person’s life and exploring ways that a person can restore each of those areas while recovering from their abuse.

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Insurance Providers

United Healthcare

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Under the ACA, United Healthcare provides coverage for an Essential Health Benefits (EHB) package in 10 benefit categories. Mental health and substance abuse services, including behavioral health treatment, is included as one of those 10 benefit categories. These services are covered in all non-grandfathered Individual plans and non-grandfathered, fully insured Small Group plans for both in-exchange and off-exchange plans. Large Group fully insured, Self-funded (ASO) plan, and Grandfathered plans are not required to include these benefits.

All United Healthcare plans that cover EHB have removed annual dollar and lifetime dollar limits for those services, including Large Group (insured and ASO). Lifetime dollar limits must be removed from Individual grandfathered plans, but they are not required to remove annual dollar limits.

In reviewing a sample plan from United Healthcare, both inpatient and outpatient services are covered:

United Healthcare chart

WellPoint Group

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Wellpoint Group, which is now known as Anthem Blue Cross, includes an Optum Behavioral Health Benefit. These benefits are provided at the same levels as those covered under the IBEW Local 18-sponsored Anthem Blue Cross medical plans. In some cases, services require pre-authorization, copayment, and/or deductible, depending on the Anthem Blue Cross plan elected.

The benefits do not charge for obtaining a referral, and they allow members to access information and develop personal goals at liveandworkwell.com as often as you want at no additional cost. Those interested can get more information by contacting Optum Behavioral Health at 877-449-6710.

WellPoint Group chart

Kaiser Permanente

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Kaiser Permanente covers several different services qualifying as substance use disorder treatments. While most of its HMO plans require a Plan Physician to refer the member before care can be received from a specialist, referral or prior authorizations are not required to receive most care from mental health services or substance use disorder treatment. Hospital inpatient care for Substance Use Disorder Treatment is also covered.

Kaiser Permanente chart

These services are covered only when the Services are for the diagnosis or treatment of Substance Use Disorders. A "Substance Use Disorder" is a condition identified as a "substance use disorder" in the most recently issued edition of the Diagnostic and Statistical Manual of Mental Disorders ("DSM").

Humana

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Humana provides evidence-based treatment options based on behavioral health guidelines for common behavioral health conditions. Humana psychiatrists review these guidelines biannually and aid in standardizing treatment options based on the most effective interventions available.

Humana no longer offers individual health plans.

Aetna

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Aetna provides coverage for drug addiction and substance use disorder and also provides a range of literature to their members on a variety of related topics:

Aetna also offers providers a Screening, Brief Intervention, and Referral to Treatment (SBIRT) program to help identify alcohol and drug abuse and reduce and prevent dependence on these substances. The program allows health care professionals to get reimbursed to screen for alcohol and substance use.

Healthcare Service Corp.

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Health Care Service Corporation is an Independent Licensee of the Blue Cross and Blue Shield Association and the largest customer-owned health insurer in the United States. They operate through Blue Cross and Blue Shield® Plans in Illinois, Montana, New Mexico, Oklahoma, and Texas.

Under one of its sample Blue Cross and Blue Shield® Plans in Illinois, the following is covered:

Healthcare Service Corp.

Blue Cross and Blue Shield® Plans in Illinois outline how they cover substance abuse as part of their Behavioral Health Services. Some of the covered services include:

  • Alcohol or drug treatments
  • Care during a hospital stay
  • Community-based behavioral health services
  • Crisis services
  • Day treatment at a hospital
  • Intensive outpatient program
  • Medication-assisted treatment
  • Outpatient services, such as medication management, therapy, and counseling
  • Residential treatment of substance abuse

These plans do not cover experimental procedures or non-drug therapies or services from non-licensed providers.

As outlined in the member handbook, care may be provided in a community setting, such as a day program or a doctor’s office, or in a person’s home. A member can access behavioral health services by communicating with their Care Coordinator and other members of the Care Team. These people can assist in finding help and help you schedule appointments or screenings. A member’s Care Team may also include health outreach workers (community health workers) or other mental health experts.

Cobra Coverage

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Coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA), allows you to remain on your employer’s group health insurance plan even after you no longer remain an employee. The full premium amount is likely your responsibility through COBRA, but the benefits of the plan should remain in full effect so long as you are current on your payments. If your health insurance plan covered substance abuse treatment and other mental and behavioral health services, that should continue for as long as your COBRA coverage lasts.

Compsych

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ComPsych offers employee assistance programs, including behavioral health and wellness programs. ComPsych serves over 109 million people throughout the U.S. and 160 other countries. The company works with organizations to provide behavioral health programs to their employees, including high-quality care. ComPsych matches employees in need of behavioral health services with the appropriate level of care and case management to ensure the best outcomes.

With ComPsych insurance plans, pre-approval is required for specific treatment; however, the plans may cover one or more forms of rehabilitation. In some cases, the insurance may cover up to 80 percent of inpatient or outpatient costs at in-network facilities.

Managed Health Network (MHN)

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Managed Health Network (MHN) provides coverage for behavioral health services, including mental health services and substance use disorder treatment. These benefits usually cover:

  • Therapy, psychiatry, or psychology sessions.
  • Various levels of care at a treatment facility based on each individual’s unique needs. Treatment ranges from care administered several hours per day to multiple days each week to 24-hour care (inpatient treatment).
  • Follow-up and aftercare following treatment.

While MHN does not provide or administer prescription drug or pharmacy benefits, individuals should contact MHN or refer to the Summary Plan Description or Evidence of Coverage documents for information about prescription drug coverage. Those documents can also provide guidance on:

  • Eligibility for plan benefits.
  • Preauthorization required for certain services.
  • Covered services by MHN network providers.
  • Covered services for out-of-network providers.
  • Out-of-pocket costs.
  • Exclusions and limitations to benefits.

People with MHN coverage who feel they need help with mental health or substance abuse issues can call the toll-free number listed on their ID card. MHN has behavioral health representatives available 24/7 who can:

  • Assess your needs and possible referrals via telephone.
  • Answer questions about substance use/behavioral health benefits.
  • Provide crisis intervention.
  • Help secure an appointment with a provider (urgent cases can secure an appointment within 48 hours; less urgent cases can secure an appointment within 10 business days).
  • Authorize initial sessions on the phone if a practitioner is selected on the call. Alternatively, callers can take the time needed to find an appropriate counselor and call back to receive an authorization once they have a practitioner in mind.

First Health

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First Health insurance provides plans through its First Health network, Cofinity network, and First Health Complementary Network. The First Health network is a national PPO network that has over 5,500 hospitals, nearly 115,000 ancillary facilities, and over 1.5 million health care professional service locations. The Cofinity Network is a leading PPO network in Michigan and Colorado that offers negotiated rates to remain competitive in the marketplace. The First Health Complementary Network is a broad national network that can provide savings outside of the primary network. This offers lower out-of-pocket costs via in-network doctors and hospitals.

The best way to find out which substance abuse services are covered, members should call the number on the back of their insurance card or visit the website and log in to view member benefits.

Beacon Health Options

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Beacon Health Options offers more than 30 years of experience and its reputation as a leader in delivering specialty mental health and substance use disorder (MHSUD) solutions. Beacon Health Options focuses solely on behavioral health and has in-house clinical staff that can provide the highest standard of care. This insurer works with employers to provide unique solutions to employees in order to improve health outcomes and boost productivity.

The MHSUD offerings cover the following:

  • Autism Program: This program provides comprehensive support for children with autism. The program also offers support to families via Applied Behavioral Analysis services, coordinated care management, and coaching support.
  • Opioid Management Program: Opioid use disorder (OUD) is treated as a chronic illness. As such, the treatment utilizes a chronic disease model of care that promotes community-based care coordination, medication-assisted treatment, and other recovery-oriented interventions. Beacon Health Options provides comprehensive opioid management via analytic, network, and clinical expertise. The program helps to support providers in caring for members through the recovery journey towards long-term improved health.
  • Depression Management: Depression management services offer support, coaching resources, and clinical care for people who suffer from depression at every level. These services include advanced case management for individuals who may need more intensive services.
  • Psychiatric Disability Management: Psychiatric Disability Management provides transition support for employees coming back to the workplace after an extended absence spent recovering from behavioral health issues.

Beacon’s provider networks are built around behavioral health and substance use disorder needs so that members are able to work with skilled specialists and receive timely care. The national network includes more than 100,000 behavioral health providers and facilities, including custom networks for individual specialties such as autism, opioid use disorder, and diagnostic specialty units.

Magellan

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Magellan Healthcare provides solutions for behavioral and specialty healthcare and provides integrated, quality care backed by over 50 years of experience and expertise. When it comes to addiction and substance abuse treatment, Magellan deploys an integrated approach to identify at-risk individuals early and proactively. Early intervention can reduce the need for higher levels of care. Magellan offers members a network that includes more than 118,000 credentialed providers and health professionals that are equipped to combine behavioral health clinical expertise with advanced data analytics and technologies.

Magellan specializes in working with complex populations, including those with serious mental illness (SMI), autism, and opioid and substance use. Due to its specialization, the health plans are bespoke behavioral health solutions built around:

  • Predictive modeling and multi-model stratification. Providers can identify undertreated individuals and can intervene early to change the trajectory of the disease course.
  • Multi-dimensional engagement and interactions. Providers use personalized digital tools that are tailored to the individual needs of each patient.
  • Organized behavioral health delivery system. This system simplifies the member and provider experience, leading to improved quality and cost outcomes.
  • Integrated medical and behavioral care. Magellan utilizes integrated medical and behavioral care rounds, medical and behavioral care gap closures, and co-located case management.
  • Guided identification and treatment. The medical delivery system provides guided treatment by proactively finding patients within the primary care environment and referring them to evidence-based behavioral health resources.

Emblem Health (GHI)

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Emblem Health (GHI) provides covered behavioral health and substance use disorder services within its plans. Emblem health offers a network of mental health professionals to help people who may be using alcohol or drugs to self-medicate. No referral is needed and members can call Beacon Health Options at 888-447-2526, 24/7 to find a mental health provider nearby.

Members can also use the Find a Doctor tool to search “Mental Health and Substance Abuse”. This will take members to the Beacon Health Options “Find a Provider” search, which has information specific to the member’s plan.

Additional details about substance use disorder services and coverage can be found below:

Emblem Health (GHI) services and coverages

Additionally, preauthorization is not required for a Covered Prescription Drug used to treat a substance use disorder, including a prescription drug to manage opioid withdrawal and/or stabilization and for opioid overdose reversal. Ancillary charges apply, per your Member Contract. A list of covered medications can be obtained from the website. Payment information based on a 30-day supply of covered drugs is below:

Emblem Health (GHI) payment information

Amerihealth

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Amerihealth is a family of companies that provide both locally-focused health insurance plans and national-scale programs. Many of their programs cover behavioral Health Services, including all mental health, drug, and alcohol services. Plans that do cover these services allow members to self-refer to behavioral health service providers. In some cases, primary care physicians or another physical healthcare provider will need to recommend that a Member access behavioral health services.

Plans may cover diagnostic, assessment, referral, and treatment services including:

  • Inpatient and outpatient psychiatric services.
  • Inpatient and outpatient drug and alcohol services (detoxification and rehabilitation).
  • EPSDT behavioral health rehabilitation services for Members up to age 21.

Coventry

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Coventry was acquired by Aetna in 2013, making it the third-largest health care benefits company in America based on membership.

Former Coventry members can look to Aetna’s covered services, which include drug addiction and substance use disorder. Former Coventry members can also refer to the range of literature Aetna provides to their members on a variety of related topics:

Coventry (now Aetna) also offers providers a Screening, Brief Intervention, and Referral to Treatment (SBIRT) program to help identify alcohol and drug abuse and reduce and prevent dependence on these substances. The program allows health care professionals to get reimbursed to screen for alcohol and substance use.

Government Employee Health Association (GEHA)

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Government Employee Health Association (GEHA) plans cover behavioral health conditions, including alcohol addiction, drug dependency, and mental health disorders. Members of a GEHA health plan who have been diagnosed by a qualified medical professional with one or more behavioral health disorders are eligible for health insurance coverage. Under GEHA health plan rules, substance abuse problems, and mental health difficulties are treated the same as any other type of physical illness.

GEHA health plans include extensive drug and alcohol addiction treatments, initial evaluation and diagnosis, detox services, inpatient or outpatient treatment programs, and some essential aftercare services. To receive these benefits, a member’s eligibility must be certified by a GEHA health insurance representative by providing documentation that states the treatment is medically necessary.

Most addiction treatments under GEHA plans require precertification. Treatments include intensive day treatment, partial hospitalization, and intensive outpatient plans. Plans may also cover regular inpatient or outpatient recovery programs. Alcohol and drug rehabilitation facilities should take care of the precertification protocol with GEHA.


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Insurance Coverage Information

Specialized Programs Offered by Treatment Facilities

Alcohol and substance abuse treatment may combine both behavioral and pharmacological approaches. More than 14,500 specialized drug treatment facilities exist in the U.S., providing different forms of treatment that include behavioral therapy, medication, counseling, case management, and other services.

Combining Behavioral Health with Addiction Treatment

Alcohol and substance abuse treatment may also include treatment within a physician’s office and/or mental health clinics and may be delivered via inpatient, outpatient, and residential settings.

These treatments may be administered by one or more medical professionals, including physicians, nurses, psychiatrists, counselors, psychologists, and social workers. More often than not, alcohol and substance abuse treatment entails a unique combination of various methods and settings, depending on an individual’s specific needs.

How the Affordable Care Act (ACA) Is Helping Combat Substance Abuse

Since the implementation of the Affordable Care Act (ACA), individuals struggling with alcohol and substance abuse have more access to treatment and coverage for addiction and other behavioral health issues.

Depending on the type of insurance, many carriers are now required to cover these services at the same rate as they would cover other necessary medical services.

This parity has resulted in more insurance plans covering rehab, inpatient and outpatient treatment programs, detox, counseling, therapy, medications, and follow-up care.

Additionally, many rehab programs provide financing options for those who are not able to pay the entire cost upfront.

Before Insurance Coverage of Addiction Treatment

Prior to the enactment of the ACA, drug addiction was considered a pre-existing condition. With roughly 20 million Americans that have substance use disorders, it has become critical to understand how insurance coverage applies and can be used to treat drug addiction.

While not all facilities or services may accept insurance as a form of payment, many public addiction treatment programs do. Some programs may accept health insurance for at least a portion of treatment.

American Addiction Centers, Inc.

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