As a result of the legislation passed in 2010 under the Patient Protection and Affordable Care Act (Obamacare), insurance carriers are required to provide what is defined as “essential health benefits” to their clients. This is formally defined as basic benefits and services that include mental health treatment and behavioral health treatment. Treatment for substance use disorders (the diagnostic term associated with substance abuse and addiction) falls under the category of mental health treatment, and interventions like psychotherapy fall under the category of behavioral health treatment.
In addition, previous legislation has dictated that insurance providers must provide the same level of behavioral healthcare treatments as they do for primary services. Therefore, insurance companies must provide some type of coverage for issues associated with substance abuse. The exact type of coverage that is provided by these companies will vary from company to company and according to the different types of insurance plans these companies provide.
Anthem, Inc. is a health insurance company that was founded in the 1940s and previously was known as Wellpoint, Inc. It remains one of the largest profit-oriented managed healthcare companies in the United States and primarily offers Blue Cross and Blue Shield policies.
Anthem, Inc. provides services for the treatment of substance use disorders as part of its behavioral healthcare plan. Coverage for substance use disorder treatment is provided in all 50 states. Depending on the plan, Anthem offers coverage for both inpatient substance use disorder treatment and outpatient substance use disorder treatment. Anthem is the primary provider for Blue Cross Blue Shield services in:
- New Hampshire
- Most of Virginia
The particular amount of coverage that an individual has depends on the particular plan the person enrolled in and the state where the person lives. In general, Anthem offers Blue Cross Blue Shield coverage under four major types of programs:
- Bronze-level plans: These programs have the least expensive monthly premiums but also involve the most out-of-pocket expenses; in general, they cover about 60 percent of expenses.
- Silver-level plans: These plans have higher-level monthly premiums and reduced out-of-pocket expenses; in general, they cover about 70 percent of expenses.
- Gold-level plans: These plans have higher monthly premiums with more benefits, lower deductibles, and reduced out-of-pocket expenses; they generally cover about 80 percent of expenses.
- Platinum-level plans: These plans offer the most extensive coverage available from Anthem and also the highest premiums with significantly reduced out-of-pocket expenses; generally, they cover about 90 percent of expenses.
Coverage for Withdrawal Management (Medical Detox)
Depending on the plan, Anthem insurance does provide coverage for inpatient withdrawal management and substance use disorder treatment services. These services will typically involve withdrawal management (medical detox) treatment services. The amount of coverage provided depends on the individual’s plan and the particular state where they reside. These issues are typically dependent on several factors that include:
- The medical necessity of the desired treatment (see below).
- The expected length of stay, which typically will vary between 30 and 90 days
- The type of substance involved, in some cases
- Co-occurring diagnoses that also need attention
- Potential legal ramifications for substance abuse
- The individual’s history, which often includes consideration of previous attempts to enter treatment and their outcomes
The notion of medical necessity is often determined by the information provided by a referring physician, and written stipulations and guidelines followed by the insurance company. This term basically means that the treatment is necessary from a medical point of view in order to help the individual function properly and to reduce the costs associated with ramifications of not treating the particular issue in question. When individuals have serious conditions, including mental health conditions that require immediate and intensive treatment, the notion of medical necessity is often considered by insurance companies like Anthem in order to determine the level of appropriate care needed for the individual and the amount of coverage that will be applied to the particular case. Again, the amount of coverage is determined within the confines of the individual’s plan and subject to the particular state where the individual lives. Different state guidelines often regulate the extent of coverage that a company must provide.
Depending on the plan, individuals may only have sufficient coverage to enter basic withdrawal management programs as an inpatient and then transition to outpatient care, or they may qualify for more upscale treatment, such as luxury and executive treatment centers that provide numerous amenities that are not provided under basic plans. Some of these amenities include:
- Spa services
- Private rooms
- Relaxed visitation policies
- Complementary and alternative treatments, such as acupuncture, music therapy, art therapy, etc.
- Executive facilities, such as online access, private offices, etc.
Although there is no hard-and-fast rule regarding the associated out-of-pocket expenses an individual will incur, most of the programs often have a fixed deductible rate and a percentage of costs that the individual must personally be responsible for. Depending on the plan, the deductible and percentage will vary. For instance, someone may have to pay the deductible (e.g., a fixed amount of any charges for healthcare services) and a percentage of all other costs (e.g., 10 percent). Depending on the plan, certain services may not be covered at all; these are services that are not deemed to be medically necessary for the individual’s recovery. Often, services that are not covered at all include:
- Food prep
- Laundry services
- Treatments that are not deemed to be medically necessary for the particular issue (e.g., acupuncture, complementary and alternative treatments, yoga, etc.)
The extent of coverage for outpatient services will also vary, but outpatient coverage is often more extensive. The decision to initially become involved in an inpatient or outpatient treatment program is based on the particular situation, the needs of the client, the information provided by the referring physician, and the particular plan the individual has.
The Anthem website reports that their coverage involves the complete spectrum of behavioral healthcare, including:
- Access to specialists, including therapists and physicians
- Access to acute healthcare and freestanding clinics and hospitals
- Coverage for research-based treatment programs that are provided by certified healthcare providers
Tips to Ensure the Best Possible Coverage
There are several things that can be done to ensure a person maximizes their coverage.
- Ensure that a physician initially examines the individual and makes a recommendation for substance use disorder treatment.
- Understand the particular criteria that the specific plan requires for coverage. Failing to ensure that a treatment is a medically necessity and documented as such by a licensed physician may lead to denial of coverage.
- Contact an insurance representative (the phone number for customer service should be on the back of the insurance card) and discuss coverage with them.
- Go on the Anthem website to find a list of local in-network treatment centers.
- Contact centers that fit the needs of the individual and discuss the situation with their intake advisors, so they can seek preauthorization for the potential client.
- Ask questions. Take time to understand exactly what is being covered, what the client is responsible for, and ask about any other particular issues that may surface, such as treatment for co-occurring disorders (e.g., depression, anxiety, etc.), emergencies, access to adjunctive treatments in the program. etc.
Click below to learn about some of the major insurance providers with policies that may cover drug treatment or ancillary services.