Will UnitedHealth Insurance Cover Drug Treatment Programs?

UnitedHealth Group is the largest health insurer in the United States, the Washington Post publishes. With a mission to help people live healthier lives, UnitedHealthcare and Optum provide medical benefits to Americans in all 50 states. In an attempt to simplify healthcare, UnitedHealthcare provides consumers with access to discounted care through a network of trusted relationships with over 1 million healthcare providers and doctors. Offering healthcare benefits to employers, individuals, military services members, retirees and their families, and Medicaid and Medicare recipients, UnitedHealthcare provides quality health and wellness care at cost-effective rates to nearly 30 million Americans.

Under the Mental Health Parity and Addiction Equality Act (MHPAEA), health insurance providers are required to provide insurance coverage for drug and alcohol abuse, as well as mental health concerns, at rates similar to those of other covered surgical and medical procedures. In 2014, over 20 million Americans battled addiction to drugs and/or alcohol, the National Survey on Drug Use and Health (NSDUH) reports. Both Optum and UnitedHealthcare insurance plans, which are both subsidiaries of UnitedHealth Group, provide coverage for drug treatment programs, offering a full continuum of care.

Enrolling in a Substance Abuse Program Using UnitedHealth Insurance

There are many different types of insurance plans and coverage options, and the best way to know exactly what is covered and how to use insurance to pay for drug treatment is to contact a UnitedHealth insurance provider directly. These highly trained professionals can help a person better understand their coverage and how to navigate using health insurance to pay for services.

UnitedHealthcare insurance contracts with providers to offer drug treatment services at discounted rates to its members. These facilities are considered “in-network” providers. Depending on the type of plan a person has, individuals may also go to providers that are “out of network,” for a higher, less discounted rate. In general, HMO (health maintenance organization) insurance coverage plans require individuals to remain in network for services to be covered while PPO (preferred provider organization) plans allow member to obtain services from both in- and out-of-network providers for variable rates; out-of-network providers result in higher costs.

Specialty services, such as drug treatment programs, may or may not require a referral from a primary care provider before coverage kicks in, depending on the insurance policy held by the member. Typically, UnitedHealthcare insurance does not require prior authorization before covering drug treatment programs; however, they do ask that members give advanced notification to the insurance provider before receiving these specialty services (both inpatient and outpatient services).

Insurance coverage may also require that a person first attempt an outpatient program before coverage for a residential treatment program is provided. This is called the “fail first” or “step therapy” mentality, which is a nationally recognized protocol that helps people to move between levels of care as needed. Certain forms of treatment, such as inpatient medical detox, may also require documentation deeming them “medically necessary” before coverage is authorized.

Examples of drug treatment services that may be covered by UnitedHealthcare include:

  • Detoxification
  • Inpatient medical detox
  • Outpatient rehabilitation
  • Inpatient drug treatment services
  • Group therapy provided by substance abuse counselors, psychologists, or physicians
  • Educational and behavioral therapy group sessions
  • Individual and family therapy sessions
  • Medications for withdrawal from narcotics when provided by a physician
  • Medications that meet specific criteria and requirements

UnitedHealthcare also offers health insurance via Medicare for those who meet the criteria for government-subsidized insurance policies, and drug treatment programs are often covered. Individuals covered by UnitedHealthcare Medicaid coverage are allowed up to 190 days of inpatient rehabilitation in a psychiatric hospital in their lifetime. There are several exceptions to this rule, and an extended inpatient stay for rehabilitation can be covered when it is documented to be medically necessary. There are no limitations on coverage for length of time in outpatient drug treatment programs.

In order to find and enroll in a substance abuse treatment program and use UnitedHealthcare insurance to pay for services, members should contact their provider in order to determine exactly what is required for coverage to be considered. Providers at substance abuse treatment facilities can also help individuals and families to better understand how to use their health insurance coverage to cover costs, and what may and may not be covered.

UnitedHealth Insurance Coverage and Policy Basics

When using health insurance to help pay for services, there are two main ways it works: A person pays for the services up front and then seeks reimbursement from the insurance company; or an insurance claim is filed at the time the services are rendered, and the person merely pays a copay at the time. A copay is generally a fixed amount that is set by the insurance provider to be paid by the member at the time services are received. This amount may be different for different types of facilities. For instance, emergency department copay fees are typically higher than those collected for wellness or primary care provider appointments. They may also differ between outpatient and residential drug treatment programs.

Along with the copay, there may also be other out-of-pocket costs that members seeking drug treatment may incur, even when insurance coverage is used. Insurance companies may provide coverage at a certain percentage, say 80 percent for drug treatment programs, and the member will then be responsible for paying for the other 20 percent of the cost. In general, insurance policies will have set annual out-of-pocket maximum amounts, and when a person reaches this amount in a calendar year, the remainder of the costs will be covered at 100 percent.

There may also be a deductible amount. This is a minimum amount of money that a person must pay out first before services are considered covered. If a member has a $500 deductible, for instance, then they must pay for services up until that amount is reached and then the coverage will begin at whatever the percentage the policy is set to cover. In order for a person to be eligible to use health insurance to cover drug treatment services, they must also keep up with monthly premium payments, which are the monthly costs associated with maintaining an insurance policy.

There are different levels of insurance coverage, and they may cover different things at different rates. UnitedHealthcare plans include the following options for coverage:

  • UnitedHealthcare Choice: This is an “open access” plan that requires members to use services that are in network. It offers fixed copay amounts, and members can obtain specialty services without a referral.
  • UnitedHealthcare Choice Plus: This plan offers the same benefits as UnitedHealthcare Choice plans; however, members are able to seek treatment services from out-of-network providers for higher out-of-pocket costs.
  • UnitedHealthcare Options PPO: With this plan, members are able to receive services from whomever they choose while in-network providers are still offered at lower rates than out-of-network providers.
  • HRAs (Health Reimbursement Accounts): This is specialized account that employers own and out of which, they reimburse members for medical services.
  • HSAs (Health Savings Accounts): Members may put money into these accounts and use the funds to pay for medical expenses.

Within insurance plans, there may also be levels of coverage, ranging from bronze to silver to gold and even platinum. Bronze policies typically have the lowest monthly premiums and highest deductibles while the reverse is true for gold and platinum plans. UnitedHealthcare plans may also be used with coinsurance policies to pay for drug treatment services as well if members have multiple insurance providers and policies in place.

UnitedHealthcare may require verification for specialty treatment services, and providers can help members with this. Contact the insurance company and/or treatment provider directly in order to learn what is necessary for coverage to be maximized.


Click below to learn about some of the major insurance providers with policies that may cover drug treatment or ancillary services.