How to navigate insurance coverage for addiction treatment in Boynton Beach rehab center

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If you are struggling with addiction and have decided to seek treatment, the very first thing that you will find out is that it can be quite expensive. Of course, this is largely due to how the insurance system works in the U.S. Basically, it is presumed that you have medical insurance that will help pay the bills. However, that does not necessarily mean that your insurance will cover all of your treatment expenses. In fact, you will need to learn to navigate insurance coverage for addiction treatment in Boynton Beach rehab center. Since Bright Futures Boynton Beach is all about allowing you to focus on your recovery instead of its financial aspect, we have prepared an article that can help you with this. We will cover the various types of health insurance coverage, common types of healthcare plans, and how to use ACA to its full potential.

Navigating insurance coverage for addiction treatment in Boynton Beach rehab center 101

In 2022, around 12% of people in the U.S. were uninsured, while 68% had private health insurance coverage, with around 22% having public health insurance coverage. While health insurance was once considered a luxury item, these days over 90% of all Americans are medically insured. However, as you might already know, not all health insurance is the same, and there are varying degrees of coverage limits. To start understanding what sort of options you may have at your disposal, we need to look at the following:

  • Types of health insurance coverage
  • Covered drug addictions
  • Types of covered facilities
  • Coverage for mental health issues
  • Medication-assisted treatment
person trying to navigate insurance coverage for addiction treatment in Boynton Beach rehab center by looking at a map
To navigate insurance coverage for addiction treatment in Boynton Beach rehab center, you will need a “map”.

Due to how many factors there are, there is no simple answer to the question “Does insurance cover rehab?”. In general, yes, insurance will cover at least a portion of your rehab costs but there are situations in which you may not be able to utilize your insurance to pay for your treatment. The best way to find out the specifics of your health insurance plan is always to talk directly to your insurance provider. Alternatively, you may also want to go through an admissions process in a Boynton Beach treatment center of your choice as they will be able to help you figure out your insurance coverage as well.

Either way, you will still want to know exactly what your insurance might (and might not) pay for. The first step to understanding your health insurance coverage is to look at the various coverage types.

Types of health insurance coverage

If you want to navigate insurance coverage for addiction treatment in Boynton Beach rehab center, you first need to know what sort of treatments are covered by your insurance plan. Depending on the type of plan, your insurance might cover the following:

  • Medical detox
  • Inpatient rehab
  • Outpatient treatment
  • Follow-up therapy
  • Treatment for co-occurring disorders

Furthermore, you will want to figure out any other applicable laws or rules that may pertain to your situation. For example, you will want to figure out does FMLA cover substance abuse treatment in your state. Most of the time, you will be able to get leave under FMLA for the purposes of addiction treatment but some states may have other laws that might influence your decision. It is always in your best interest to spend some time searching for any applicable laws, as some might even help you.

blocks spelling the word "law"
The letter of the law changes from one state to another.

Covered drug addictions

Most health insurance plans follow the rules of the insurance marketplace. These rules state that insurance providers have to provide care in 10 healthcare categories, one of which is addiction. Most of the time, you will not have to worry about any drugs being covered, as they all are. We say “most of the time”, as some health insurance providers may still make exceptions. If you have health insurance from a large, reputable, provider, however, you will not need to worry about any particular drug coverage. It is usually enough to simply ask “Does Humana cover rehab?”, for example. The reason behind the comprehensive coverage is quite simple, too.

Health insurance companies do not want to pay for all the testing that would be required to determine the exact type of drug that was being used. Nor do they want to pay for all the other expenses such as figuring out how the drug was made, where it came from, or whether it was mixed with some other drug. No, they choose to take the easy route and simply cover all drugs. Of course, the plan itself needs to provide addiction coverage in the first place. Many health insurance plans forgo addiction coverage to provide their clients with lower premiums, for example.

If you need to figure out whether your plan provides addiction treatment coverage, the best thing to do is to request a one-page summary of all the benefits and therapies that are covered, as well as their prices. Under the ACA (Affordable Care Act), your health insurance provider is required to provide you with such a summary.

Types of covered facilities

Now that we’ve established that almost every health insurance plan will provide coverage for virtually any drug, what about treatment centers? There are more than 15,000 addiction treatment centers in the U.S., are they all covered by health insurance? The simple answer is no, but you still have plenty of choices. Most of the time, however, your health insurance company will provide you with a list of treatment facilities that you can visit and make use of your coverage. These facilities are usually referred to as “In-network” providers. Most people who ask “Does Tricare cover rehab?”, for example, get the answer “Yes, but only within specified facilities.” Furthermore, depending on your specific health insurance plan, there may be other benefits or limitations to choosing an in-network provider.

a treatment center from the outside
There are more than 15,000 treatment centers in the U.S., and your insurance might not provide coverage for all of them.

For example, your plan may reimburse you for full treatment costs in an in-network center (inpatient detox, residential treatment, outpatient therapy, etc.) while only providing coverage for specific treatments in other rehab centers. This is something you definitely need to inquire about when talking to your insurance provider. Otherwise, you may be facing considerable out-of-pocket costs.

Speaking of out-of-pocket costs, you can expect that there will always be some, regardless of your insurance coverage. The exact specifics vary from one plan to another, which is yet another line of inquiry that you might want to follow.

Coverage for mental health issues

One of the most important things to do when you want to navigate insurance coverage for addiction treatment in Boynton Beach rehab center is to figure out whether your insurance covers mental health treatment. According to NIM research (Prevalence, Treatment, And Unmet Treatment Needs of US Adults With Mental Health And Substance Use Disorders), almost 8 million adults that are diagnosed with addiction also have co-occurring mental health issues. Traditionally, there was quite a stigma around mental health which is, thankfully, largely gone now. These days, under the ACA, all health insurance plans are required to provide a similar level of care for mental health issues as for medical issues.

That being said, the current parity laws are somewhat unclear. They do not clearly define the exact type of mental health conditions that insurance plans have to provide coverage for. However, most reputable insurance providers will no longer differentiate between physical and mental care. Even so, you will still want to discuss the topic with your plan administrator. There is always a chance that your particular plan has some unique inclusions or exclusions and you want to know about them ahead of time.

blocks spelling the word "anxiety"
Most of the time, mental health coverage is no different than medical coverage.

Medication-assisted treatment

While almost every health insurance plan will provide drug rehab coverage, medication-assisted treatment (MAT) is something different. First, MAT is considerably more expensive than most other treatment types. Therefore, you can expect that there are some insurance limitations, as well. For example, it is not simply enough to ask “Does Blue Cross Blue Shield cover rehab?”. What you need to ask is whether Blue Cross Blue Shield will cover MAT. On average, most private health insurance plans will provide MAT coverage if the person is being treated for heroin or similar opioid-based addiction. Medicaid/Medicare plans, on the other hand, will only cover the cost for MAT if the treatment is absolutely required to achieve continued sobriety. In other words, if it is determined that an individual is capable of achieving sobriety without MAT, your Medicaid/Medicare plan will not pay for it.

If you believe that your recovery requires MAT to succeed, you will want to get in touch with your insurance provider and ask about all the applicable benefits, services, therapies, and copayments before you proceed. It may so happen that your plan provides extensive coverage but it might also happen that your coverage has considerable limitations.

Categories of health plans

When it comes to health plan categories there is one simple thing to understand: The more valuable the metal tier, the more comprehensive the plan. There are four metal tiers: Bronze, Silver, Gold, and Platinum.

Bronze plans

Bronze plans have the lowest monthly premiums but come with the highest costs when you do end up needing care. The deductibles found in bronze tier plans can be considerably high, ranging to several thousand dollars a year. These plans are usually best for people who want to protect themselves from worst-case medical scenarios but want to do that in a low-cost way. Under a bronze-tier plan, your insurance company will pay, on average, 60% of your medical costs.

a bronze bell
Bronze plans cost the least, but they provide the least coverage as well.

Silver plans

Silver plans are somewhat special. They require a moderate monthly premium, come with moderate care costs, and offer lower deductibles than bronze plans. However, silver plans can also qualify for cost-sharing reductions. Unfortunately, not everyone can qualify for these extra savings. To find out if you qualify for a silver plan with extra savings, all you need to do is fill out a Marketplace application. Note that these extra savings are only applicable to silver plans, other plans cannot benefit from them. If you can qualify for extra savings, however, silver plans will usually be your best choice.

Gold plans

Gold plans come with a high monthly premium, low care costs, and low deductibles. They are ideal for people that are willing to invest a bit more into their health insurance each month so that they can get very affordable care when they need it. On average, gold plans will cover 80% of the treatment cost.

Platinum plans

Platinum plans have the highest monthly premiums, the lowest care costs, and very low deductibles. This usually means that your platinum plan will usually “start paying its share” much sooner than other plans. They are best for people who tend to require a lot of care and are able to pay a very high monthly premium. A platinum plan will, on average, cover 90% of the treatment cost.

Common types of healthcare plans

Even though there are literally tens of thousands of different healthcare plans, most of them fall under three common types:

  • Health Maintenance Organization (HMO) plans
  • Preferred Provider Organization (PPO) plans
  • Point of Sale (POS) plans
two people trying to navigate insurance coverage for addiction treatment in Boynton Beach rehab center
Choosing between HMO, PPO, and POS plans can be complicated.

Each plan type comes with specific advantages and disadvantages, and it might be in your best interest to understand them all. The reason why answering a simple question such as “Does Oscar cover rehab?”, for example, will not suffice is that Oscar can offer a variety of health insurance plans. Though, to be completely honest, almost every health insurance plan will provide addiction treatment coverage under certain conditions.

Health Maintenance Organization (HMO) plans

The best way to start learning to navigate insurance coverage for addiction treatment in Boynton Beach rehab center is to look at the most popular type of health plan – HMO plans. These plans will require you to choose your primary care physician (PCP) who you will refer to for almost all your medical needs. By choosing a PCP, you will be able to form a more personal relationship with your doctor and they will get to know your whole health history. You are still capable of visiting another doctor but you will require a referral from your PCP.

The major selling point of these plans is that they have low or no deductibles and their overall coverage costs are usually lower than most other plans. However, this is only true if you are staying within the preferred network. If you need to visit a treatment center that is outside of the network, you can expect hefty out-of-pocket costs.

Preferred Provider Organization (PPO) plans

Unlike HMO plans, PPO plans will allow you to visit other healthcare professionals without requiring a referral from your PCP. This allows for greater flexibility, as you can visit any doctor regardless of their network status. You will still pay less for in-network doctors, however. In other words, if your treatment center is within your preferred network, your treatment costs will be lower. This is usually the reason why most people think of in-network costs when they ask “Does AvMed cover alcohol rehab?” for example. Furthermore, PPO plans will not require you to choose a primary care physician.

several doctors looking at an x-ray image
Under a PPO plan, you can see specialists without the need for a referral.

The downside of these plans is that this added flexibility incurs additional costs. Your monthly premiums are going to be higher, for one, and there may be additional costs. Therefore, you will want to consider whether the option to see different specialists at any point, without needing a referral, is worth the added cost.

Point of Sale (POS) plans

POS plans are quite similar to HMO plans, with one large distinction. Unlike HMO plans, PPO plans offer the possibility to visit a provider outside of your network, albeit under certain circumstances. These circumstances vary from one plan to another, however, and it can all get quite complicated. In fact, each insurance company has its own rules regarding its POS plans. If you are considering a POS plan, it is simply not enough to ask “Does UMR cover rehab?” as the answer will usually be yes, no, and maybe. What you want to do is have a long chat with your insurance provider and clarify all the details before you sign anything.

Aside from utilizing the common health insurance plans, you can also pay for rehab in a variety of other ways. Most notably, by utilizing ACA provisions.

How to navigate insurance coverage for addiction treatment in Boynton Beach rehab center by using the Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act (ACA) has quickly become one of the most popular ways to pay for addiction treatment. Traditionally, many health insurance plans denied coverage under the clause of pre-existing conditions. The most important ACA provision is that addiction treatment is no longer considered a pre-existing condition for insurance purposes. Furthermore, ACA provides need-based tax credits to eligible individuals, further lowering the cost of care.

What does ACA cover?

The best thing about ACA is that it considers addiction treatment practically the same as any other medical treatment. This means that you can get coverage for all of the following:

  • Clinic visits
  • Drug/Alcohol testing
  • Addiction evaluation
  • Brief intervention
  • Family Counseling
  • Medication for addiction treatment
  • Anti-craving medications
  • Home health visits
  • Inpatient services
  • Medical detox
the word cocaine on a whiteboard
All ACA plans include drug treatment coverage.

You can get an ACA health insurance plan from any Health Insurance Marketplace, including Some states tend to run their own marketplaces while others may base their federal medical plans on the state’s specific Medicare/Medicaid coverage. The only slight problem with these plans is that you need to be eligible for them first.

Who is eligible?

The fact of the matter is that you will have to deal with the word “eligibility” whenever you want to navigate insurance coverage for addiction treatment in Boynton Beach rehab center. All the best health insurance plans have certain requirements, after all. For ACA plans, the eligibility requirement is that your income needs to be between the federal poverty level (FPL) and four times FPL. The limit itself will change according to family size, and it changes every year. In 2023, the FPL for 48 contiguous states and the District of Colombia looks like this:

  • 1 Person in the family/household – $14,580
  • 2 Persons in the family/household – $19,720
  • 3 Persons in the family/household – $24,860
  • 4 Persons in the family/household – $30,000
  • 5 Persons in the family/household – $35,140
  • 6 Persons in the family/household – $40,280
  • 7 Persons in the family/household – $45,420
  • 8 Persons in the family/household – $50,560

If your family includes more persons, you can simply add $5,140 for each additional person and figure out your FPL that way. The FLP is different in several states, namely Alaska and Hawaii, where it is slightly higher. For example, the FPL for a 1-person household is $18,210 in Alaska and $16,770 in Hawaii.

Will your treatment provider accept your ACA plan?

While most treatment providers will accept ACA plans, some will not. The best way to figure out whether your Boynton Beach rehab center accepts your insurance plan is to get in touch with them directly. At Bright Futures Treatment Center, we pride ourselves on an easy and fast admissions process, where we will help you make the most out of your insurance. We can’t say that we will accept every single health insurance plan but we do work with all the major insurance providers and can accommodate most ACA plans as well.

The very best way to navigate insurance coverage for addiction treatment in Boynton Beach rehab center is to connect your insurance provider with your treatment center of choice. That way, you can allow them to “talk it through” among themselves and figure out exactly what is covered and what is not. While you can definitely be more active in the process, it is usually best if you focus on your recovery instead of dealing with the financial aspects of it.

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