Blue Cross Blue Shield (BCBS) is one of the oldest and largest providers of health insurance in the United States, providing coverage for one out of every three Americans, with 36 local and independent BCBS companies covering over 100 million people. BCBS offers coverage for individuals in every zip code and every state in the United States through independently operated BCBS companies and subsidiaries.
Coverage may differ from state to state through the different entities of BCBS and the dictation of local regulations. Providing experienced and trusted healthcare coverage through community-based companies, BCBS has partnerships with more than 90 percent of all hospitals and doctors across the nation.
Behavioral health services include both substance abuse and mental health concerns. Blue Cross Blue Shield insurance offers coverage for these services, as the Affordable Care Act (ACA) demands that these services be considered “essential” and covered at the same rates as other surgical and medical procedures.
Addiction is a public health concern that one out of every 12 American adults suffered from in 2014, the National Survey on Drug Use and Health (NSDUH) reports. It is considered a treatable disease, and specialty care and insurance companies like BCBS recognize the need to offer treatment for drug and alcohol abuse to aid in recovery. There are different types and levels of coverage within BCBS, and in order to determine if drug and alcohol rehab is covered directly, it is best to contact the insurance provider directly. Members may use the three letter prefix on their BCBS insurance member ID card in order to access services and resources online or call the number on the back of their card. Depending on individual coverage policies, Blue Cross Blue Shield insurance may cover at least a portion of drug and alcohol rehabilitation services.
Levels of BCBS Coverage
In general there are two main types of health insurance coverage provided by BCBS companies: HMOs and PPOs. An HMO is a health maintenance organization that asks members to remain “in network” to receive care. Providers that are considered in network have contracts with BCBS to provide services for discounted rates. With an HMO plan, members must use these in-network providers in order for services to be covered. The HMO network is typically within a specific local geographic area. Individuals will typically need a referral from a primary care provider (PCP) for specialty services.
A PPO, preferred provider organization, is more flexible in that it allows members to seek care “out of network”; however, these services are typically covered at lower percentages. This means that while a person who has a PPO plan can seek treatment services and medical care through providers that are not in network, they will likely pay more in order to do so. With a PPO, members may not need a referral from their PCP in order to seek specialty medical or mental health services.
Another option is a HSA, or health savings account, which members can place money into to be used to pay for healthcare services. This is a tax-free flexible spending account.
In addition to the different main plan structures of HMO, PPO, and HSA, there are also “metal tiers” of BCBS insurance plans. The tiers offered may vary from state to state, but in general, there are three or four different options, including:
- Bronze: Coverage is usually provided at around 60 percent; deductibles are high and monthly premiums are low.
- Silver: Coverage is provided at around 70 percent (or more if the member is eligible for a cost-sharing reduction subsidy, which is based on income and other factors). Deductibles are not as high as the bronze plan and not as low as the gold, and monthly premiums are also in the middle.
- Gold: Coverage is typically provided at 80 percent; deductibles are low and monthly premiums are high.
- Platinum: This plan is not offered in all areas. Platinum plans may offer coverage at 90 percent or more; deductibles are quite low, and monthly premiums are the highest.
In general, a bronze-level plan will incur the most out-of-pocket expenses, which are costs that a person pays in addition to their monthly premiums that are necessary to keep coverage current. Deductibles are set amounts that a member must reach before coverage kicks in at the agreed-upon percentage. For example, if a person has a $500 deductible and the insurance plan provides 80 percent coverage, a person will first need to reach the $500 threshold in medical expenses and then the insurance provider will cover the rest of the services at 80 percent while the member will pay the remaining 20 percent. There is also usually an “out-of-pocket annual maximum” amount for each calendar year. After a member reaches this amount, which will differ depending on the individual coverage policy and plan type, the insurance provider will cover the rest of any medical expenses at 100 percent.
Another out-of-pocket expense is the copay. A copay is a set amount that a person will pay at the time they receive healthcare services. These amounts are typically more for emergency department services than for primary care provider visits. Copays can also differ for specialty services and are set by the insurance provider. A copay is typically collected each time a member uses services and not generally considered part of the annual maximums or used toward deductibles.
Using Blue Cross Insurance to Find and Cover Rehab
One of the best resources for explaining health insurance coverage, and understanding what is covered and what is not, is the insurance provider directly. Members should contact their individual provider for the most up-to-date and detailed coverage information. Treatment providers can also typically help people to navigate health insurance and how to use it to its maximum effectiveness.
Many Blue Cross Blue Shield companies provide access to a behavioral healthcare coordinator (BHCC) to help members find and enroll in treatment services, including drug and alcohol rehab when needed. These services are confidential and can match people up with behavioral healthcare services that are covered under their specific policy. The Substance Abuse and Mental Health Services Administration (SAMHSA) also provides a behavioral health services locator tool to help people find treatment options near them. These providers will usually have specialty trained professionals on hand to help people understand their insurance coverage and how it may be used to help pay for drug and alcohol treatment services.
Many times, health insurance policies request that members first receive a referral from their PCP before entering into a drug or alcohol treatment program. The services must often be deemed to be medically necessary, and it may be required that an individual first attempt an outpatient addiction treatment program before coverage will be provided for the more comprehensive residential treatment options.
BCBS insurance plans may cover detox services, when needed, especially in the case of significant alcohol, opioid, or benzodiazepine dependence, as these substances often require medical detox services for safety purposes. Family, group, and individual counseling and behavioral therapy sessions and treatment for co-occurring mental health disorders are also generally covered services. Community-based treatment services, such as relapse prevention and education programs, are often covered. Members may need to obtain verification that certain addiction or substance abuse services are necessary from their provider before insurance will cover these specialty services.
Addiction treatment services may be covered in whole or just in part, depending on the specific insurance plan and policy in place. There may also be a limit on length of time spent in an addiction treatment program in a year or lifetime, or the number of covered visits may be mandated. Members should contact their insurance provider in order to learn exactly what is covered and at what rate before entering into drug or alcohol rehab. Most substance abuse treatment providers will accept Blue Cross Blue Shield insurance.
Click below to learn about some of the major insurance providers with policies that may cover drug treatment or ancillary services.