Blue Cross Blue Shield Drug Rehab Coverage
Increasingly, the medical community and health insurers are recognizing addiction for what it is: a disease. As a result, more and more insurers are providing coverage for patients suffering with addiction and drug dependency who require treatment—including Blue Cross Blue Shield. Addiction is characterized by repeated, compulsive use of harmful substances despite negative consequences. As individuals continue to abuse these substances, the brain undergoes fundamental changes that alter the user’s brain chemistry and disrupt normal and healthy thinking patterns and behavior.
As researchers, physicians, and the general public have become aware of the drug epidemic and how it affects users and their families as well as the communities they live in, insurance companies have been expanding their coverage to include drug treatment and rehabilitation programs. This article will cover Blue Cross drug rehab coverage and explore the options available to those covered by Blue Cross Blue Shield.
Under the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, insurance providers are federally mandated to provide the same level of coverage for mental health and addiction treatment as they offer for traditional medical care.
About Blue Cross Blue Shield
The Blue Cross Blue Shield Association (BCBSA) is a network of 36 separate, locally-operated health insurance companies that provide health insurance coverage to over 100 million patients across the United States. Blue Cross was founded in 1929; however, the Blue Cross Association as it exists now did not emerge until the 1960s. Blue Shield was founded in 1939 and became the Blue Shield Association in 1948. The two associations finally merged in 1982 and have operated together as the BCBSA ever since. Blue Cross Blue Shield partners with over 90 percent of healthcare providers nationwide, and can be accessed by individuals in every ZIP code in the United States.
As of June, 2017, Blue Cross Blue Shield covered more than 100 million people, including:
- 82 percent of the nation’s Fortune 500 companies
- 2 million small business employees
- 17 million union workers and their families
- 6 million employees of the federal government
- 7 million Medicaid recipients
- 1 million people through the Medigap supplemental insurance program
- 1 million people through the Medicare Advantage program
Blue Cross Blue Shield will typically cover drug rehab and treatment for its members, but the extent of this coverage depends on the member’s state of residency, the specific Blue Cross Blue Shield company he or she is covered by, and his or her insurance plan. Additionally, some Blue Cross Blue Shield companies may cover different types of drug treatment and, as is the case with most insurance companies throughout the United States, members are typically required to pay out of pocket until they reach their deductible.
Blue Cross Blue Shield Association affiliates include the following:
- Health Care Service Corporation (HCSC)
- State options such as Horizon Blue Cross Blue Shield of New Jersey
Continue reading to learn more about Blue Cross drug rehab coverage and Blue Cross Blue Shield drug rehab facilities.
Blue Cross Blue Shield Insurance Plans
Specific plans and coverage options vary from provider to provider, but Blue Cross Blue Shield companies generally offer two types of plans: health maintenance organization (HMO) plans and preferred provider organization (PPO) plans.
All HMO and PPO plans provide members access to a network of physicians, hospitals, and other health care professionals and services, but the way care is covered and delivered is different.
Health Maintenance Organization Plans
With HMO plans, Blue Cross Blue Shield members choose a primary care physician to oversee their all of care. In order to see a specialist or other health care professional, except in cases of emergency, patients must receive a referral from his or her primary doctor if they wish to have the visit covered under their insurance plan. For example, if a patient is suffering with depression or compulsive behavior, his or her primary care physician may choose to refer him or her to a psychiatrist within the patient’s network to receive specialist treatment. Once this referral is made, an HMO insurance plan will generally cover the specialized care.
One exception to this rule is that female patients are not required to receive a referral in order to have obstetrician/gynecologist (OB/GYN) visits, routine pap smears, and other such treatments covered.
Preferred Provider Organization Plans
Unlike with HMO plans, PPO plans do not require patients to have a primary care physician. Blue Cross Blue Shield members who are covered under a PPO plan may visit any health care professional, physician, or specialist they choose without a referral from their primary care doctor. PPO plan members may also see doctors outside of their network; however, a higher copay is typically involved with such visits and not all services are covered. In this way, PPO plans offer more flexibility than do HMO plans.
Blue Shield Blue Cross in State Exchanges (Tiered Coverage)
In the Health Insurance Marketplace (which was introduced in 2013 as part of the Affordable Care Act) insurance plans are grouped into three or four categories—depending on an individual’s state of residency. Each state has its own marketplace, and plans may be categorized as “platinum,” “gold,” “silver,” or “bronze.” These tiers offer varying levels of coverage and differing monthly premiums and deductibles.
Blue Cross Blue Shield plans are generally structured as follows:
- Platinum plans cover approximately 90 percent of patients’ medical costs, and carry the highest premiums and the lowest deductibles.
- Gold plans cover approximately 80 percent of patients’ medical costs, and carry higher premiums and lower deductibles.
- Silver plans cover approximately 70 percent of patients’ medical costs, and carry comparatively lower premiums and higher deductibles.
- Bronze plans cover approximately 60 percent of patients’ medical costs, and carry the lowest premiums and the highest deductibles.
To find out more about Blue Cross Blue Shield plans and coverage, visit the BCBSA website here.
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.
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 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 (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 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.
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:
- Cognitive behavioral therapy (CBT)
- Holistic therapy
- Group therapy
- Couples and/or family therapy
- Alcoholics Anonymous (AA)
- Narcotics Anonymous (NA)
- SMART Recovery
- Sober living homes
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 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.
Selecting a Treatment Center
The first step in selecting a drug treatment center is determining whether inpatient or outpatient rehabilitation is right for you. There are benefits and drawbacks to both types of treatment and it is important to consider your unique circumstances, needs, and preferences when making this important determination. Your primary care physician as well as your family, friends, or other loved ones may act as helpful resources. Factors that are likely to affect your decision to enter inpatient or outpatient treatment include:
- The specific substance(s) you are addicted to and/or abusing
- The severity and duration of your addiction
- Your individual biology/genetic makeup
- Your responsibilities (children, job, school, elderly parents, pets, etc.)
- Your current living situation and environment
- Are there drugs and alcohol in the home?
- Are there other people living in the home who are suffering from addiction or abusing drugs or alcohol?
- Are the people in your environment supportive of your decision to enter rehab?
- Are there people who can help you maintain the home, look after your children and/or pets, and pay any bills you may have during an inpatient stay?
- Are you able to commute to and from an outpatient treatment center multiple times per week for appointments, therapy sessions, drug tests, etc.?
Once you have determined whether inpatient or outpatient treatment is right for you, it is important to contact your Blue Cross Blue Shield insurance provider to determine what services you need, and whether or not these services will be covered by your individual insurance plan. This will help you determine which specific drug rehab facility is the right fit for you.
Local vs. Out of State Rehabilitation
It is not uncommon for addicted individuals to choose to enter an inpatient treatment program in a state other than their state of residence. There are a number of reasons someone might choose to do this, including: to recover in an environment that is free from distractions and is conducive to a healthy, sober-friendly atmosphere or in order to receive treatment in a particular out-of-state facility that may provide care and services or amenities that are not available in the person’s state of residency.
Whatever the addicted individual’s reason for choosing an out-of-state treatment center, it is important to understand how this decision may impact the cost of treatment and your Blue Cross Blue Shield insurance coverage.
It is important to keep in mind that those covered by HMO plans must choose an HMO-contracted treatment center, whether in-state or out of state, while PPO plan holders may choose any treatment center they find appropriate. However, if someone with a PPO plan chooses to undergo treatment in an out-of-network rehabilitation center, coverage is likely to be far less generous. This is true for both in-state and out-of-state treatment facilities.
Another factor that may significantly affect the cost incurred by the member is that Blue Cross Blue Shield plans rarely cover the cost of transportation to and from a treatment facility. In fact, most major health insurance companies in the United States do not cover transportation costs. Therefore, it is important to consider the out-of-pocket expenses you are likely to incur if you choose to enter an out of state rehab facility, even if it is an in-network facility.
Affordable vs. Luxury Treatment Facilities
Each individual is unique, and different types of treatment centers and levels of services and amenities are right for different people depending on their needs and preferences. Some treatment centers are relatively inexpensive and minimal when it comes to special amenities beyond the necessary treatments. Other facilities provide additional amenities and offer a more retreat-like environment in which patients can recover. These “luxury” rehabs may offer private (not shared) rooms, spa treatments, and other amenities. However, luxury treatment centers tend to be more expensive.
Some Blue Cross Blue Shield plans may cover a portion of a policyholder’s luxury treatment. Individual policies differ in the extent of their coverage of these types of extra services and amenities. In most cases, policyholders will be expected to pay at least a portion of these additional costs.
Find a Treatment Center
It is important to keep in mind that, like other insurance providers, Blue Cross Blue Shield plans may only cover a portion of a patient’s drug treatment costs. As previously discussed, it is important to contact your specific provider in order to make sure you understand which costs you will be responsible for and exactly what services and care are covered under your plan.