How Does Insurance Coverage Work For Addiction Treatment?

In the United States, insurance poses one of the most significant barriers to accessing substance use treatment. For the 70% of Americans with commercial or private insurance, finding a program that aligns with their policy can be challenging. This article aims to shed light on which programs insurance carriers typically cover and the potential out-of-pocket expenses.

When you reach out to a treatment program, they will conduct an intake assessment to gather crucial details about your substance use, treatment history, and insurance information. Subsequently, the treatment program will conduct a verification of benefits (VOB) to understand the specifics of your policy, including your out-of-pocket maximum (OOP), co-insurance, deductible, and the portion already met.

After the VOB, someone from the treatment program will contact you to provide an estimate of the expected costs. Here’s a quick overview of key terms: Your deductible is the initial amount you must pay for services before insurance covers the provider’s charges. Co-insurance refers to the percentage of service costs you need to bear until you reach your OOP maximum. Once your OOP max is met, the treatment should be fully covered. Typically, treatment centers collect deductibles and, in some cases, co-insurance upfront before billing the insurance company directly.

An important note regarding Anthem insurance is that they still practice a method called “paid to member” for out-of-network services. In this case, they will send payment directly to you, and you are responsible for passing these checks to the treatment center.

How Much Does Treatment Cost?

Regarding the cost of treatment, below is a breakdown of services covered by insurance and their average cash rates. If you have good insurance coverage, some of the out-of-pocket expenses listed here may not apply to your situation. However, it is advisable to read this article to better understand what each program offers.

1. Detox Programs: Most insurance carriers cover detox programs, but the average out-of-pocket cost ranges from $250 to $500 per day. Costs can vary significantly depending on the treatment facility.

2. Residential Treatment: This option is also covered by most insurance and typically costs between $1,000 to $2,000 per day.

3. Sober Living: Insurance companies usually do not cover sober living programs, resulting in costs ranging from $800 to $10,000+ per month. The price difference is due to the varying quality of services provided.

4. Day Treatment (PHP) and Intensive Outpatient Programming (IOP): Both PHP and IOP options are almost always covered by insurance providers. PHP may have out-of-pocket costs ranging from $5,000 to $15,000 per month, while IOP costs range from $3,000 to $10,000 per month.

5. Outpatient (OP): This level of care usually costs less than $5,000 per month and is covered by most major insurances.

Remember, it’s essential to review your insurance policy and clarify any doubts about the treatment programs to make informed decisions about your substance use treatment journey.