Insurance Companies and Addiction Treatment Coverage

Health insurance coverage for addiction treatment

As per the 2012 National Survey on Drug Use and Health, over 21 million Americans struggled with a substance use disorder last year. Yet, less than 2.5 million received treatment at a rehabilitation facility and of those who needed treatment a quarter did not receive it because they lacked health insurance coverage.[1]

Fortunately, under the new healthcare laws, addiction treatment is considered “an essential health benefit” that must be covered by the commercial health plans.

In fact, as the rolling healthcare reform measures came into effect, the quantity of people seeking treatment for addiction had been expected to more than double over the next year.

Up until about 40 years ago, addiction was not recognized for what it actually was: a diagnosable and treatable disease.

Even though over the years public and medical viewpoints of addiction as a person’s moral failing have evolved into more comprehensive insights, stigmas around addiction and its treatment still cloud people’s decision to seek professional help.

Insurance plans are intended to make healthcare easier to access and more affordable, without any discrimination associated with the assistance needed.

Understanding Your Addiction Treatment Coverage

Insurance companies may not always openly claim responsibility, as of now, over 43 U.S. states mandate commercial group health insurers to cover addiction treatment.

If a family member, you, or a loved one is in need of addiction treatment, it’s vital to fully understand your insurance policy and know your rights as a policyholder.

In many instances, treatment centers are open to managing the process of finding your insurance benefits coverage in accordance with their center’s fees.

Even though it is a great hassle-free option, it is highly suggested for you also to contact them yourself.

Begin with your health plan: the policy should define a complete range of addiction care as the National Alliance for Model State Drug Laws (NAMSDL) include “intervention, detoxification, inpatient rehabilitation, outpatient treatment, and intensive outpatient, family, and codependency treatment.”

Be aware of the fact that it is illegal for insurance companies to discriminate against patients because of addiction. This is based on The Mental Health Parity and Addiction Equality Act of 2008.

You can also consult with state legislators, the state insurance department, or the Office of the Attorney General.

If you are uncertain, contact your insurance provider for purposes of clarification of the policy with them.

Furthermore, check the NAMSDL website for the identification of your state’s leading agency for addiction treatment facilities. Despite differences across states, the website can help clarify the exact laws and policies. [2]

Some Other Resources Include:

Man near the river in addiction treatment recovery

The U.S. Department of Health and Human Services – it is a website where you can read what the Affordable Care Act (ACA) includes. – It is an official ACA website. You can view your benefits, change benefits, and enroll in the program. So you can better understand health insurance plans, you can access an online guide. – It is the site for Medicaid where you can check benefits, see a list of facilities by concern, and enroll.

State Health Insurance Assistance Program (SHIP) – It is a program that gives free counseling, health insurance information, and assistance for those enrolled in Medicare.

Substance Abuse and Mental Health Services Administration (SAMSHA) – It can provide consumers information on their rights in regards to health care.

Health insurance coverage

Despite the fact that insurance policies cover differing amounts of treatment services, most plans will include one or more of the following:

  • Assessment – Normally, it is fully covered.
  • Detox – Commonly, it is frequently covered, but rapid detox and ultra-rapid detox may not be covered.
  • Outpatient treatment – generally mostly covered.
  • Inpatient (residential) treatment – tends to be partially covered.

Insurance typically covers assessments, detoxifications, outpatient treatment and inpatient or residential treatment. Insurance policies coverage applies the same way to addiction treatment as it does for medical conditions.

They will, however, cover what a professional determines to be “medically necessary,” as assessed by their case manager or medical provider.

A professional assessment is usually entirely covered by an insurance policy, and an official diagnosis of an addiction can alter the treatment coverage by your provider.

Determining Your Coverage and Questions to Ask

  • Contact Member Services at your insurance company – have your membership identification number ready.
  • Jot down the names of any representative(s) you speak with, alongside any notes about the conversation.
  • Inquire about the “levels of care” covered for addiction treatment
  • Ask about in-network and out-of-network providers and the percentage covered by insurance for each.
  • Enquire about co-pays and deductibles.
  • Ask what your maximum out-of-pocket expense will be.
  • Ask to determine what your insurance company’s criteria is to assess medical needs.

Regardless of the insurance you have or what you know about your plan, you should try to contact the admissions department of the program you’re considering. Programs have many ways of flexing benefits to make plans work. [3]

Does President Trump’s Stance on the Affordable Care Act Affect My Ability to Attend Rehab?

Hands holding a family for insurance coverage

Currently, treatment for addiction is listed as one of the “ten essential health benefits” covered by the Affordable Care Act. It enables thousands in need of addiction treatment to attend rehab they desperately needed to recover.

However, due to President Trump’s insistence on repealing ACA, fluctuations on the coverage can be expected.

Since President Trump plans to replace or substitute for the Affordable Care Act are still underway, the information on addiction treatment handled for those with government insurance remains uncertain and can only be confirmed by directly contacting the providers.

Sana Ahmed photoAbout the Author:

A journalist and social media savvy content writer with wide research, print and on-air interview skills, Sana Ahmed has previously worked as staff writer for a renowned rehabilitation institute focusing on mental health and addiction recovery, a content writer for a marketing agency, an editor for a business magazine and been an on-air news broadcaster.

Sana graduated with a Bachelors in Economics and Management from London School of Economics and began a career of research and writing right after. The art of using words to educate, stir emotions, create change and provoke action is at the core of her career, as she strives to develop content and deliver news that matters.



The opinions and views of our guest contributors are shared to provide a broad perspective of addictions. These are not necessarily the views of Addiction Hope, but an effort to offer discussion of various issues by different concerned individuals.

We at Addiction Hope understand that addictions result from a combination of environmental and genetic factors. If you or a loved one are suffering from an addiction, please know that there is hope for you, and seek immediate professional help.

Published on November 5, 2017
Reviewed By: Jacquelyn Ekern, MS, LPC on November 5, 2017.
Published on

About Jacquelyn Ekern, MS, LPC

Jacquelyn Ekern founded Addiction Hope in January, 2013, after experiencing years of inquiries for addiction help by visitors to our well regarded sister site, Eating Disorder Hope. Many of the eating disorder sufferers that contact Eating Disorder Hope also had a co-occurring issue of addiction to alcohol, drugs, and process addictions.