Blue Cross Blue Shield Coverage of Drug Treatment

In most cases, Blue Cross Blue Shield plans will cover drug treatment for those suffering with addiction to drugs or alcohol; however, the extent of this coverage is dependent on the member’s state of residence and his or her individual policy. It is important to contact your insurance company directly in order to fully understand the specific care and services your plan covers.

In order to have their treatment covered, patients with HMO plans must receive treatment at one of the many HMO-contracted Blue Cross Blue Shield drug rehab facilities across the country, while PPO plan members have access to a wider range of treatment centers. The various types and stages of drug treatment and their coverage under Blue Cross are discussed below. It is important to keep in mind that coverage will vary depending on your state of residence and individual plan.

Detox

Detoxification (or “detox”) is the process by which an addicted individual physically withdraws from frequent or compulsive use of an addictive substance. Detox and withdrawal are often the first step in a Blue Cross drug treatment program. Not all patients require a detox period. Depending on a variety of factors, including the extent and duration of abuse, the severity of the psychological and physical addiction, and the individual patient’s biology and genetics, a physical detox may not be deemed necessary. However, for many people recovering from addiction and drug abuse, detox is an important step in the treatment process.

For individuals struggling with addiction or dependency on benzodiazepines, opioids, alcohol, methamphetamines, and certain other substances, medical detox is generally covered under Blue Cross Blue Shield plans. Because the detoxification and withdrawal process from these substances is particularly difficult and, at times, dangerous, most insurance plans will cover medical detox (either on an inpatient or outpatient basis) when medical supervision is deemed necessary by a physician or addiction specialist.

Inpatient Rehabilitation

Inpatient rehabilitation (also sometimes called “residential” treatment) involves intensive, round-the-clock supervision and assistance throughout the recovery process. Patients in residential treatment are medically and psychologically monitored during detox and withdrawal and throughout their stay. Patients live and sleep at the facility and participate in individual and/or group therapy, peer support activities, educational programs, relapse avoidance training, etc.

Inpatient treatment is generally the most expensive form of drug treatment (other than acute hospitalization) and is often recommended to those with severe or long-lasting addictions. Residential treatment can be either short- or long-term, and may last anywhere from three months to a year, depending on the individual needs of the patient and his or her risk factors.

Depending on the state, Blue Cross Blue Shield plans will often cover at least a portion of a member’s inpatient rehabilitation program costs when it is deemed medically necessary.

Typically, with Blue Cross Blue Shield plans such as those offered by Anthem (the largest for-profit company in the BCBSA), the patient must pay a certain dollar amount in addition to a given percentage of their total rehab costs. For example, a patient may be responsible for paying $600 plus 12 percent of their total treatment costs.

It is important to remember that, like all Blue Cross Blue Shield coverage, Anthem Blue Cross drug rehab coverage varies from state to state and plan to plan. In addition, in order to receive coverage, members with an HMO plan must select an HMO-contracted treatment center, while members with PPO plans have the flexibility to choose from a wider range of treatment centers. Those with PPO plans will, however, likely incur much higher costs if they choose an out-of-network provider.

Outpatient Rehabilitation

Outpatient rehabilitation is a broad category, encompassing everything from low-intensity drug education programs to intensive day treatment programs that share many characteristics with inpatient rehab. Outpatient programs are often recommended to individuals struggling with less severe addictions or those who do not require medical supervision during detox. Withdrawal from certain drugs, such as cocaine and marijuana, are less likely to be dangerous or life-threatening, compared to opioids and benzodiazepines such as Valium and Klonopin.

Outpatient drug treatment tends to be less expensive than inpatient treatment, but does not offer 24-hour supervision and assistance. However, outpatient rehab typically includes many of the same tenants involved in residential treatment such as individual and/or group therapy, educational programs, and peer support. Outpatient treatment may be suitable for those who have a strong support system of family and/or friends or a job they are unable to leave for an extended inpatient stay.

Blue Cross Blue Shield plans will often cover at least a portion of a patient’s outpatient rehabilitation costs. Unlike inpatient rehabilitation, for which Blue Cross Blue Shield typically requires members to pay a given dollar amount plus a percentage of the total cost, outpatient rehabilitation coverage under Blue Cross Blue Shield generally requires members to pay a given percentage of their total treatment costs, in addition to a daily copay. For example, a given Anthem Blue Cross Blue Shield plan may expect a member to pay 12 percent of their total outpatient treatment costs, in addition to a $15 copay for each day they attend treatment.

For members who require outpatient treatment, Anthem and most other Blue Cross Blue Shield affiliates will generally agree to cover up to a specified number of days, and will decide whether or not to extend coverage based, in part, on the patient’s attendance record and participation in treatment. If you are considering outpatient treatment, it is important to consider your ability to regularly attend treatment and pay the daily copay.

Aftercare Programs

Following successful completion of an initial inpatient or outpatient treatment program, physicians and addiction specialists typically recommend that patients continue to participate in structured recovery efforts in order to maintain their sobriety. Aftercare programs are an important part of the recovery process for most addicted individuals, as they provide structure, community, and professional support.

There are a wide variety of aftercare and transitional options available, and treatment centers will typically work with you to develop a detailed and individualized aftercare plan. Most aftercare programs incorporate some kind of ongoing individual and/or group counseling component.

Below are a few common aftercare options:

These and other aftercare programs are designed to help recovering individuals adjust to sober living, build supportive and lasting relationships with peers, and maintain their sobriety long-term.

Blue Cross Blue Shield plans will often cover a portion of the cost of a member’s aftercare costs. As with inpatient and outpatient treatment programs, Blue Cross Blue Shield drug rehab coverage of aftercare programs such as individual or group counseling, AA and NA, behavioral treatments, and 12 step programs vary from state to state and plan to plan.

In addition to the member’s state of residency and their individual plan, other factors that often contribute to the extent of aftercare coverage include: the duration of the treatment (aftercare programs may be ongoing), the patient’s commitment to regularly attending therapy sessions and/or appointments, and whether or not they consistently abide by the rules and expectations of their aftercare program.

As previously discussed, the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires United States health insurance companies to provide the same level of coverage to their members for mental health and addiction treatment as they offer for medical care and services. Therefore, if your Blue Cross Blue Shield plan provides a high level of coverage for traditional health and medical care, it is likely that it will also offer generous coverage of mental health and substance abuse treatment. However, it is important to contact your insurance company directly to make sure you understand the specifics of your plan and what services and care are covered.