When you or a family member needs addiction treatment, the last thing you want to deal with is hefty payments involved in getting help. And as sad as it is, one of the biggest reasons that people don’t get the treatment they so desperately need is prohibitive costs. The National Survey on Drug Use and Health (NSDUH) from 2016 actually found that among addicts that acknowledged they needed help but never got it, almost one-third of them didn’t do so simply because they didn’t have the money or insurance to cover it. The good news is that no matter what your current health insurance plan is, there is an option for getting treatment without having to pay for the whole thing yourself. Health insurance coverage varies in the percentage providers will pay, sure. And how much you pay for treatment may rely heavily on what your deductibles are. But most health insurance carriers in WA State compensate a portion of the cost for outpatient or inpatient treatment. And in fact, the overwhelming majority of insurance companies across the country are now required by law to provide substance use disorder treatment. Even still, if you live in Washington State and are in need of an addiction treatment program, it can be hard to know whether or not your provider covers enough of the cost to make treatment a viable option. Even further, you may not be sure what the inclusions and limitations of your insurance are at any given center. This guide to insurance coverage for treatment and rehabilitation will help break down what you need to know about some key terms and laws regarding coverage as well as what most providers will pay for and what they won’t.
“Get the help you need today. We offer outpatient assistance, so you can maintain your work, family, and life commitments while getting the help you deserve!”
Why Would Insurance Cover Addiction Treatment?
In general, there are three main reasons why an insurance provider would choose to cover addiction treatment.
- It’s legally required for many plans
- It can help cut down on future payments
- It provides a higher level of care, usually at a higher monthly cost to customers
Addiction Treatment Coverage Is Legally Required
One of the most exciting changes in addiction treatment comes from the fact that today, most insurance providers are required by law to at least partially cover treatment costs. In the past, it was wholly up to providers whether or not to provide such care to their customers. There are two major legislative changes that have brought about this change.
- The Affordable Care Act (ACA) – The ACA did more than just make insurance coverage mandatory for all U.S. citizens. It also required all individual and small group insurance plans to expand their plans to cover 10 essential health benefits or EHBs. These are:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
As a result, all individual and small group insurance plans are now required by law to offer treatment services for individuals struggling with addiction thanks to the Affordable Care Act.
- The Mental Health Parity and Addiction Equity Act (MHPAEA) – Originally passed in 2008 for group health plans alone, this act was amended in 2010 to apply to individual health insurance coverage plans as well.
What the MHPAEA accomplished was to make coverage for mental health or substance use disorders equivalent in value to coverage for medical/surgical problems under a provider.
For instance, after the MHPAEA was passed, insurance companies could not require higher deductibles or co-payments and could not impose stricter treatment limitations (e.g., days of coverage, number of visits), for mental health problems compared to physical ones.
Ultimately, mental health became just as much of a concern and basis of insurance coverage as physical health.
Because of these two acts, then, addiction treatment coverage benefits because:
- Addiction treatment coverage is required for most providers thanks to the ACA.
- Treatment has to be equal in value and scope compared to other disorders thanks to the MHPAEA.
Addiction Treatment Saves on Future Costs
Insurance companies have come to relate addiction as a treatable medical condition that would otherwise cost them a lot, if not dealt with. Therefore, most insurers are willing to cover the costs of addiction treatment in WA State. They understand the effects of substance abuse and consider addiction treatment a form of preventative care. The Surgeon General, for example, reports that “every dollar spent on substance use disorder treatment saves $4 in health care costs and $7 in criminal justice costs.” Drug rehab insurance coverage, then, is considered an economical way of preventing expensive treatments later due to long-term physical abuse on the body.
Addiction Treatment Coverage Provides a Higher Level of Care
Finally, some insurance providers offer coverage for treatment simply because it’s a marketable benefit that they can use to attract customers. And it’s more of an attractive benefit today than it ever has been. In 2016 alone, more than 20.5 million Americans struggled with a substance use disorder according to the American Society of Addiction Medicine (ASAM). And thanks to the raging opioid epidemic and the rising popularity of extremely potent drugs like fentanyl, being addicted has never been deadlier. Offering comprehensive treatment coverage for this debilitating disorder, then, can be seen as a major plus for providers.
Types of Insurance in Washington State that Cover Addiction Treatment Programs
This is a brief look at the types of insurance available in Washington for addiction recovery programs. Insurance companies have come to relate addiction as a treatable medical condition that would otherwise cost them a lot, if not dealt with. Therefore most insurers are willing to cover costs of addiction treatment is WA State. They understand the effects of substance abuse and consider addiction treatment as a precautionary medical concern. Drug rehab insurance coverage is considered an economical way of preventing expensive treatments later due to long-term physical abuse on the body.
Public Insurance
If you have public insurance, it’s likely that you can get affordable inpatient treatment in Washington as it will likely be subsidized. A few treatment facilities will even be subsidized by the government partially or completely. Income guidelines are a factor on how much your insurance is willing to cover you for. There are two major types of public health insurance: Medicare and Medicaid. Each of these programs is required to at least partially cover addiction treatment services. The extent to which they do, however, depends on the type of program and the state in which you live. On top of that, Medicare and Medicaid have different eligibility requirements as well.
- Medicare – This federally funded health care program is meant for three types of individuals in particular:
- People who are 65 or older
- Certain younger people with disabilities
- People with End-Stage Renal Disease (permanent kidney failure which requires dialysis or a transplant)
There are 4 different types of Medicare plans, each covering different aspects of health care services.
- Medicare Part A (Hospital Insurance) – This type of Medicare covers inpatient hospital services, stay at a skilled nursing facility, and several other services. It may cover some addiction treatment services like inpatient treatment if a physician deems it is medically necessary for your condition. Alcohol and benzodiazepine detoxification, for example, may be covered since they have potentially life-threatening withdrawal symptoms that should only be treated by licensed medical staff.
- Medicare Part B (Medical Insurance) – This Medicare type covers both medically necessary and preventive services. Ambulance services, certain outpatient prescription drugs, doctor’s visits, and (importantly) mental health services including inpatient, outpatient, and partial hospitalization care. In most cases, the bulk of your rehabilitation services are going to fall under this kind of Medicare. And depending on the type of treatment you receive (inpatient, outpatient, or partial hospitalization care), your coverage costs will vary.
- Medicare Part D (Prescription Drug Coverage) – This kind of Medicare adds additional coverage to reduce the costs of certain prescription medications not covered in Medicare Part A or Part B. Some addiction treatment drugs like naltrexone, Suboxone, or certain alcoholism medications may be covered by this type of Medicare. It depends on the state of residence and treatment, the type of drug, and the condition of the patient.
- Medicare Part C (Bundled Plan a.k.a. Medicare Advantage) – These plans include both Part A and Part B, as well as Medicare Part D under a single plan.
- Medicaid – A government program designed to offer health care services to the economically disadvantaged, Medicaid is also required to cover alcohol and drug addiction treatment.
However, not all individuals and families will qualify for Medicaid assistance as it’s based on income. The maximum household income for families that qualify for Medicaid (except in states that set their own limit) are:
- Family with 1 member: $12,140/yr
- Family with 2 members: $16,460/yr
- Family with 3 members: $20,780/yr
- Family with 4 members: $25,100/yr
On top of the strict eligibility requirements, some facilities do not accept Medicaid as a form of payment. For more information on the role that Medicaid plays in substance use disorder treatment, have a look at the Behavioral Health Services section on Medicaid.Gov.
Private Insurance
While you may pay more for private insurance, you also get better healthcare options available when it comes to addiction treatment. There are three main benefits of a private insurance plan when it comes to treatment coverage compared to public programs.
- They generally cover more services than public programs
- They will typically cover a higher percentage of overall costs
- They will usually be accepted by significantly more service providers, giving you more control over what type of program you can enroll in.
Here are some of the addiction recovery services that may be available with private insurance.
- Inpatient/outpatient drug or alcohol rehab
- High-end rehab which includes private rooms, private fitness instructors and fine cuisine.
- You may get the opportunity to receive holistic treatment which incorporates Eastern practices with traditional treatment.
- Assessments/testing as well as intervention and family support therapies may also be covered.
As with public insurance though, not all treatment facilities are going to accept every kind of insurance. That’s why even if you have a private insurer, it’s critical that you always verify your insurance coverage before choosing to partner with a specific program.
Small Group Insurance
Many businesses offer their employees some sort of group health insurance plan. And while different states have different regulations, a “small group” insurance plan usually applies to businesses that have 1-50 employees. The majority of group insurance packages in Washington State often include some type of coverage for addiction treatment. This is largely because the Mental Health Parity and Addiction Equity Act (MHPAEA) put a federal mandate on health insurance companies to offer alcohol and drug treatment in group plans. The law stipulates that 100 million employees are offered psychological health benefits. The funds usually have plans that cover detox, outpatient program support, residential hospitalization, and inpatient programs for the duration of your recovery.
“We accept many health insurance plans. You can get your life back in order with our outpatient program today!”
Types of Plans that May NOT Help Cover Treatment Costs
Self-Funded Plans
Contrary to a regular group plan, a self-funded health insurance plan is money set aside by a company itself used to cover their employees’ health or disability costs. These plans are much more flexible and allow employers to cater their health plans directly to the needs of their workers. However, self-funded plans are also exempt from much of the Affordable Care Act stipulations. And as a result, not all self-funded plans will offer coverage for addiction treatment services. It’s especially vital, then, that if you have a self-funded health coverage plan, you know exactly what you’re covered for, because it may not offer the same protections as other kinds of insurance.
Large-Group Plans
The essential health benefits of the ACA do not necessarily apply to large-group plans. These plans, offered by companies with either more than 50 or more than 100 employees depending on the state, must only adhere to the MHPAEA. That means that they are not required by law to cover mental health services or addiction treatment. However, businesses with more than 50 employees only tend to make up about 4% of all businesses across the country. And on top of that, since the overwhelming majority of large-group plans already offered mental health and addiction treatment services before the ACA, not much has changed. One thing that is different since the start of these laws is the fact that mental health service coverage must be comparable to physical health coverage thanks to the MHPAEA. Ultimately, most large-group plans will help pay for addiction treatment. But as with any other type of insurance, it’s still incredibly important that you actually verify coverage rather than assuming you have it.
Grandfathered Plans
With very few exceptions, all health insurance plans are required to adhere to the 10 essential health benefits (EHBs) listed above. However, one of those exceptions is a grandfathered plan. These plans may be individual or group-based and must have been started before March 23rd, 2010. And though this is almost a decade ago, it’s important to remember that the plan start date isn’t necessarily when you started using it. If, for example, your health insurance comes from a group plan offered by an employer, you may have simply been added to an older plan rather than receiving an all-new one. Just because you began receiving benefits years after this cutoff date, then, doesn’t mean your plan isn’t grandfathered – and not required to offer the same benefits of other ACA-compliant plans. It’s also worth noting that a grandfathered plan cannot maintain this status if it’s been drastically changed since the cutoff date. A grandfathered plan can lose its status if it:
- Significantly cut or lowered coverage
- Raised coinsurance
- Significantly raised copayments
- Significantly raised deductibles
- Significantly lowered employer contributions
- Added or decreased a yearly limit on what the health plan pays
Be sure to have a look at some of the other major coverage requirement differences between regular and grandfathered plans by checking out the government-run Healthcare.Gov page on the subject.
Number of WA State Insurance Carriers Who May Cover Addiction Treatment Programs
Some of the Washington insurance providers who may cover addiction treatment programs are as follows:
- Aetna
- Anthem
- Blue Cross
- Blue Shield
- Cigna
- Director’s Guild
- Healthnet
- Humana
- Molina
- Magellan
- Pacificare
- Primera Blue Cross
- Priority Health
- Union Pacific Railroad
- United Health Care
- United Teacher Association
- Value Options
- Western National
- Medicare
Even when you have coverage, you still need to pay close attention to what coverage you qualify for as well as what kinds of payments your company will provide. The above are some examples of insurance providers in Washington that cover some of the drug rehab costs, but there are more. Northpoint Seattle Recovery, for example, is one treatment center in WA State that works with several of the most popular insurance companies. Nearly all personal health insurance policies include a type of addiction treatment coverage. The key is to find out what rehab center will work with your plan and how much it will cost you realistically.
How To Find Out If Your Insurance Will Cover Drug Rehab
Generally, the easiest way to find out if your insurance in WA State covers your drug or alcohol treatment program is to speak directly to the center you want to go to. Rehab centers in Washington aim to ease your pain while finding out the small details of your insurance plan. By offering you the free service of looking into your insurance plan, drug rehab centers do the legwork for you. You can contact your insurance company in WA State directly by phone, email, or in person. You may want this to be your last option. Usually, your insurance company is going to want some distinct information on medical recommendations, where you plan to go and the type of treatment you’ll be getting. As a result, this should usually be your last step in the process.
Detox is Expensive – Will Your Insurance Help You Pay for Drug or Alcohol Detox?
There are several levels of treatment when it comes to substance use disorders. And detoxification and rehabilitation aren’t the same. They’re not even always part of the same program. A detox program in Washington State is a phase that you or your family member will go to before rehabilitation can occur. It’s when the body is first cut off from the substance of abuse and often results in incredibly uncomfortable physical and psychological symptoms called withdrawals. Detox is usually considered part of the overall treatment for alcohol or drug dependency and is an essential step in ensuring long-term sobriety. That’s because one of the most grueling parts of recovering from an addiction is pushing through the painful withdrawals. And in fact, without expert care during the process, most addicts can’t get through it alone without turning back to using. Often, the detox unit is within the inpatient rehab center itself. Outpatient programs may not offer detoxification but could provide you with an affiliate program nearby. Sometimes, drugs like buprenorphine or other opioid replacement therapies will be used as part of the treatment program. And some insurance companies in certain states may also cover these medications. Most state-funded detox centers accept some state health insurance policies. Your health insurance may help cover the treatment costs but may expect you to pay for the room and board charge in most cases. While there are free services or very low-cost services, they may not be custom-suited to you and your loved one. On top of that, the quality of care may not be anywhere near as high as a private detox provider. And in a critical state like withdrawal, this lack of care may end up leading to a potentially fatal relapse in some cases.
“We treat both addiction and co-occurring disorders and accept many health insurance plans. Take a look at our outpatient program today!”
Intensive Outpatient Programs As an Option
Outpatient programs and intensive outpatient programs (which offer a higher level of care) are a popular option due to their cost-effectiveness. Centers like Northpoint Seattle in WA State offer IOP programs that give patients a similar quality of care as inpatient programs, with much more flexibility. As the intensive outpatient programs are more affordable, it’s likely that insurance will cover a greater amount of the costs. For outpatient professional services under the substance abuse services guidelines, generally you pay a small deductible (less than $100) plus about 30% of the total cost. As costs don’t tend to run too high anyway, this type of program should be quite reasonable. If you are able to utilize the intensive outpatient program, you generally receive a higher quality of service than a typical outpatient program without paying for the extra room and board of inpatient treatment.
How to Get the Right Information About Costs From Your Washington Insurance Company
In order to gain valuable information about your drug rehab benefits through your Washington State insurance, you first need to know what to ask. The following questions are specific to what your benefits are in relation to your insurance. When you ask clearly, you get clear answers about the percentage of coverage you gain from various rehab treatment services.
- What are the criteria for getting maximum drug rehab benefits (doctor referrals, recommended rehab centers etc)?
- What options are available to me in terms of treatment?
- Is detox covered?
- Are Inpatient Programs covered for as long as the doctor states is necessary?
- Are Outpatient Programs covered?
- What is my coverage for detox?
- What is my coverage for Inpatient Programs?
- What is my coverage for Outpatient Programs?
- What is my coverage for residential hospitalization?
- What is my coverage for long-term Inpatient Treatment?
- What centers welcome my insurance plan?
- What centers will I get the highest percentage of coverage?
- Will there be deductibles on any of the substance abuse services?
- What will the percentages of the deductibles be?
Fast Check Your Addiction Treatment Benefits Online
When you’re looking for help with an addiction issue, either with yourself or a family member, you want answers quickly. In Washington State, there are some centers that allow you to verify your addiction treatment benefits online, like Northpoint Seattle. Insurance companies can be challenging at a time when you really need answers. One of the priorities of seeking help for addiction is to find out what services are within your budget. Centers like Northpoint Seattle deal with insurance companies every day so they can help you figure out the percentage of coverage you’ll receive. For centers that offer online verification, it’s usually just a small form to fill out, and you’ll know quickly what your coverage will be.
The Details of Deductibles and Your Drug Treatment Program
Your deductibles work similarly for addiction treatment programs as they would for any other medical treatment you might receive. Most health insurance policies will require you to pay for a portion of your own treatment. The type of payment is co-pay or a deductible. Co-pays are a certain amount of money that is usually quite affordable. You need to pay directly to doctors or the rehab center and your health insurance pays a portion. With deductibles, you must pay for your healthcare costs up to a certain amount for the year before your health insurance coverage kicks in. So for example, with deductibles, you have to pay anywhere between $500 – $5,000 within the year in order for your health insurance to start paying for your rehabilitation for addiction. This is a fairly standard method the health insurance companies use. It may be a wise idea to plan the time of year (if possible) that you will go to rehab.
Limitations for Treatment Coverage
Not only does insurance coverage vary from policy to policy but so does an addict’s needs. Treatments and levels of addiction in Washington State are different and how your insurance company covers the treatment is different too. A large percentage of insurance companies in Washington and the rest of the country cover you for the length of stay that has been deemed a necessity. Your doctor and other professionals will be able to prove your needs to the insurance company. Don’t forget that each situation is different and as you are going through recovery, your insurance provider, medical experts, and support personnel will ensure you can maintain your recovery treatment. If your insurance company feels there’s no need for you to have a high level of care, the medical team can disagree and keep you on a scholarship basis. A standard inpatient program lasts between one to three months. You should now have a good idea on what to expect with your insurance coverage in Washington for addiction treatment. There is a possibility you may have to meet deductible expectations, criteria for your insurance company, and paying out a percentage. The insurance companies realize the importance of addiction treatment for their long-term gain. Due to this knowledge as well as new insurance health care laws, they are now trying to do everything they can to help addicts move forward in their lives. And as a result, it’s likely you won’t have the manage the total financial weight of treatment on your own, getting you one step closer to vital treatment and a life of freedom and sobriety.