Across the United States, more than 36 million people are affected by opioid addiction, while more than 60 million used opioids at least once for illicit purposes.[1][2] These numbers reveal the need for accessible addiction treatment nationwide. Fortunately, if you or someone you love is struggling with substance use, help is available.
Depending on individual needs, your insurance plan may cover addiction treatment services, including detox, medication-assisted treatment (MAT), intensive outpatient treatment (IOP), and outpatient treatment. Coverage and prior authorization requirements vary by plan, so verify your benefits with your insurance company or treatment provider.
Does Insurance Cover Addiction Treatment?
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires health insurance plans to cover substance use disorders in the same way they cover medical benefits.[3] For this reason, most major health insurance plans, and all Marketplace plans, cover substance use disorder (SUD) and addiction treatment.[4]In fact, they must also cover behavioral and mental health services, which are sometimes needed alongside addiction treatment.
Covered services depend on your plan tier and medical necessity, meaning the treatment must meet your clinical needs. If you want outpatient care but a clinical assessment determines you need medically supervised detox at an inpatient level of care, outpatient care wouldn’t be covered.
The goal is to match enrollees to the right level of care to help prevent relapses.
What Addiction Treatment Services Are Commonly Covered
Insurance covers substance use disorder treatment at multiple levels of care. The type of care you need depends on your clinical needs, treatment history, and the level of support identified through an assessment.
Screening and Assessment
The first step in determining what level of care to receive for substance use disorder is to have an assessment. A clinical assessment offered by a qualified provider evaluates the client’s history with substance use, their current state of health, safety concerns, and treatment history. They may also review additional factors that could affect recovery.
In addition to determining the best level of care, a provider may use the assessment when requesting prior authorization.
Detoxification /Withdrawal Management (When Medically Necessary)
Simply put, medical detox is a form of withdrawal management. It enables a person to abstain from an addictive substance in a medically supervised environment to protect their health and safety. Certain substances require a person to be monitored during the early stages of abstinence. In some cases, providers may prescribe medication to reduce symptoms of withdrawal and drug cravings.
Detox is typically indicated for individuals who are currently under the influence of an addictive substance or have tried before to abstain without success. It’s also recommended for individuals who are at risk of serious withdrawal symptoms, such as those with alcohol use disorder.
Inpatient/Residential Treatment
Inpatient rehabilitation offers SUD treatment in a structured setting. Individuals with a history of severe substance use, safety concerns, or an unstable living environment may need this level of care. In an inpatient program, participants live at the facility to receive these services. Residential care requires participants to live in a sober-living facility and attend addiction treatment programs. Most insurance providers cover inpatient care if it’s medically necessary.
Partial Hospitalization (PHP) and Intensive Outpatient (IOP)
Partial hospitalization and intensive outpatient programs are offered on an outpatient basis, with the participant living at home while attending drug and alcohol rehab. Depending on treatment, services may take place during the day, and participants return home in the evening. PHP is more intensive and requires participants to take part in the program more days per week or more hours.
Standard Outpatient Counseling
Standard outpatient programs focus on relapse prevention. Some people attend them after leaving a more intensive level of care, while others need additional support and attend outpatient services to meet their treatment goals. Unlike inpatient care, you don’t have to stay at the facility; you can return home after treatment. This level of care is appropriate for individuals who do not need PHP, IOP, or IP.
Medication-Assisted Treatment (MAT)
Medication-assisted treatment (MAT) combines medication and behavioral therapies to treat substance use disorders SUDs.[5] While people have all sorts of substance use disorders, medication-assisted treatment programs are most commonly used for people with opioid and/or alcohol use disorders.
If a provider recommends MAT after an assessment, be sure to ask whether your insurance covers the medications.
Mental Health Treatment for Co-Occurring Disorders
When a mental health condition such as depression, anxiety, or PTSD occurs alongside a substance use disorder, it’s called a co-occurring condition. Unfortunately, one challenge can complicate treatment of the other, so it’s recommended to address both in an integrated plan. Sometimes these are referred to as dual diagnosis, but regardless of the term, addressing both supports long-term recovery.
Aftercare and Recovery Support
Aftercare and recovery support, or dual prevention programs, are offered on an outpatient basis. People attend these programs to maintain progress and continue toward recovery goals. These programs can include support groups and recovery planning.
Although offered, peer support referrals are not always covered. Ask your treatment or insurance provider whether it covers peer support programs.
Which Services are Excluded or Limited From Coverage
Most insurance plans will only cover SUD treatment services that are medically necessary.[6] Other services and treatment options may have an out-of-pocket cost or limited coverage, depending on your insurance provider network and unique clinical needs. It also depends on whether treatment requires a pre-authorization.
Your insurance plan may limit or omit coverage for:
- A longer stay (when it isn’t strictly medically necessary)
- Treatment facilities that are out-of-network
- Medications that require pre-authorization
- Luxury or executive add-ons
- Transport services (depending on your insurance plan)
When in doubt, contact your insurer and confirm what’s covered or limited upfront.
Prior Authorization, Medical Necessity, and Referrals
When you use insurance for SUD treatment, you will often come across the phrases prior authorization, medical necessity, and referrals.[7] These terms affect whether the service you’re considering is covered, so it’s helpful to understand their definitions.
- Prior authorization means you must get approval before you receive a service or treatment. The provider will submit this request to the insurance company on your behalf. They will then approve or deny the request.
- Medical necessity means a treatment must be clinically needed to treat your condition and current level of need.[8] Your insurer will consider the risks, severity, history, and safety of these treatment options before approving them.
- A referral is a request your provider submits to an outside clinic for specialty care. Some insurers require your doctor to send a referral to the selected facility before they cover the costs.
Sometimes the plan won’t approve the treatment you requested. If you and your provider believe this decision was made in error, you can ask why it was denied. You can also inquire about their appeals and review process to avoid needing legal advice. Lastly, ask what other options are available.
How to Use Insurance to Get Into Treatment (Step-by-Step)
Follow this practical checklist to use your insurance coverage for SUD treatment.
- Locate your member identification number (usually on the front or back of your card)
- Call your plan’s customer service number located on your card and obtain a list of in-network substance use disorder treatment providers.
- Call the provider you choose and schedule an assessment.
- Ask the provider to verify your benefits and submit a pre-authorization.
- Confirm your plan covers medication-assisted treatment (MAT), if recommended, through a pharmacy.
- Document all dates, references, and numbers.
| Questions to Ask Your Insurance Provider Before going through with treatment, ask your insurance company the following questions: Is the treatment provider in-network? Do these services require prior authorization? Which levels of care are covered (inpatient/outpatient/residential/detox/etc.) Will there be any co-pays or out-of-pocket costs? Are the medications for SUD covered? Do they require a prior authorization? What is the maximum length of treatment you will cover? Do you cover transportation to and from my treatment services? Note the representative’s name and the date of the call. Keep all reference numbers and jot down details about your coverage. |
How to Choose the Right Level of Care (Detox vs. Residential vs. PHP vs. IOP)
When it comes to addiction treatment, the level of care you receive matters most. The right level of care can help you reach your treatment goals and reduce your risk of relapse.
Four main levels of care exist: detox, residential/inpatient, partial hospitalization, and outpatient.
- Detox: A program that helps individuals with a substance use disorder abstain from addictive substances under medical supervision. Some individuals in detox will take FDA-approved medications to lessen the effects of withdrawal and substance cravings. This is the first step in many treatment programs and should not be used as a standalone treatment.
- Residential/Inpatient program (IP): Inpatient programs are offered as an around-the-clock treatment option for individuals with a severe history of substance use. They will reside at the facility or in substance-free housing during treatment and follow a comprehensive program while there. This program includes services like detox, behavioral therapy, group therapy, family therapy (if offered), and complementary treatments.
- Partial hospitalization program (PHP): This is more intensive than outpatient but a step down from IP. In a PHP program, clients attend a structured program during the day and return home or to a substance-free living facility afterward.
- Outpatient program (OP)/Intensive outpatient program (IOP): In an outpatient program, participants attend treatment services as needed. This includes medication management, peer support groups, therapy, and more. It’s an appropriate level of care for individuals who don’t require detox and are psychiatrically stable. IOP is a more intensive level of care for people who need services at least nine hours per week.
The provider will administer an assessment to determine the level of care needed to meet current treatment goals and clinical needs. Most people also move between levels of care as their needs change. For example, someone can begin in IP then step down to partial hospitalization or OP.
If You Need Help Right Now
If you or a loved one are experiencing severe withdrawal symptoms or suspect a possible overdose, it’s important to act quickly. Call 911 or head to the nearest emergency room immediately. Don’t wait to see if your symptoms improve. Reach out for help even if you’re unsure of the cause.
Similarly, if you’re having thoughts of suicide or a mental health crisis, you’re not alone. Call or text 988, the Suicide & Crisis Hotline. Operators who care are available around-the-clock.
Next Step
If you or someone you know struggles with substance use, has tried to quit but cannot, or feels that substance use controls your life, you may have a substance use disorder. To determine the best treatment options, contact Southeast Addiction Center TN for an assessment and benefits verification.