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Is Opioid Rehab Covered by Insurance?

  • Reviewed by: Dr. Carl Williams, Ph.D., LCADC
  • Modified:
  • Reading Time: 9 minutes
  • Reviewed by: Dr. Carl Williams, Ph.D., LCADC
  • Last Update:
  • Reading Time: 9 minutes

Learn about insurance coverage options for opioid rehab, including what treatments are covered and how to navigate your policy for access to addiction services.

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Addiction to substances, and notably opioid addiction, has been taking a toll on society for decades. However, many people have been forced to forgo necessary medical care due to the prohibitive expense of treatment.

However, many individuals with private health insurance may not realize that their plans may cover all or part of the cost of treatment for drug use disorders.

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The Impact of the ACA & MHPAEA

Will My Insurance Pay For My Rehab For Opioids?

Many more people have access to services for mental health and drug use disorders as well as parity safeguards at the federal level, thanks to the Affordable Care Act (ACA), which was introduced in 2010 and went into effect in 2014. The success of the Affordable Care Act, also known as Obamacare, may be attributed to the Mental Health Parity and Addiction Equity Act of 2008, which laid the groundwork. The MHPAEA is a federal regulation that prevents healthcare coverage insurance policies and insurance companies from imposing less favorable benefit restrictions on mental health or drug use illnesses.

The goal of the MHPAEA and ACA was to make healthcare insurance more accessible and inexpensive for everyone, which includes those with pre-existing diseases and those seeking addiction treatment for a wide variety of drugs, including opioids.

The Affordable Care Act and the Health Insurance Marketplace

The Affordable Care Act established the Health Insurance Marketplace as a hub for people and small firms to learn about and enroll in healthcare coverage. The Marketplace, accessible on HealthCare.gov, provides tools for determining eligibility for health care tax credits, comparing plans from different insurance providers, and enrolling in a health care plan.

Since opioid addiction is a SUD and all Marketplace health plans are required to cover mental health disorders and SUDs without discrimination, your insurance will probably pay for its treatment. Moreover, pre-existing diseases, such as depression or opioid use disorder, are not grounds for insurance companies to refuse coverage or charge extra.

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Equalizing Treatment

The Need For Parity and Insurance Coverage For Opioid Treatment

The ACA mandates that mental health and drug abuse problem services be treated on the same level as other medical services like surgery.

In other words, your opioid coverage will continue to provide you with the same benefits as, for example, someone who wants to have orthodontic surgery.

The parity requirements have helped get rid of things like:

  • Limits placed on out-of-pocket costs.

  • Restrictions on deductibles.

  • Time or number of visitation restrictions.

  • Constraints on care management.

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Does My Plan Meet the Parity Requirements for Opioid Rehab?

Conditions like opioid addiction and medical/surgical benefits must be addressed similarly under the legislation regarding annual and lifetime cost limits, financial obligations, and treatment restrictions.

However, the MHPAEA doesn’t mandate that large group healthcare plans or health insurance providers supply drug use disorder benefits coverage. Therefore, comprehensive group health policies and insurance companies that provide mental health and substance addiction coverage are the only entities subject to the MHPAEA’s regulations.

The Affordable Care Act, however, expands upon MHPAEA by making mental health and drug use disorder services one of the ten essential health benefits categories that non-grandfathered private and small group health plans must cover.

Please confirm the specific coverage of your health insurance plan if you wish to commence opioid treatment and are concerned that your policy does not satisfy the Parity requirement of the ACA. Read the insurance documents carefully to ensure you understand your coverage well.

Although health insurance companies are mandated to give a simple plan summary, you can still see your insurer or an independent expert for clarification. If you need assistance of this kind, don’t hesitate to get in touch with us. Rolling Hills Recovery Center’s admissions staff will walk you through your insurance plan and explain your benefits.

Rolling Hills Recovery Center offers free 24/7 opioid addiction support.

A patient navigator is ready to help. Our team of dedicated professionals are here to help 24 hours a day.

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Understanding Your Rights & What's Covered

Can My Provider Refuse to Pay for My Opioid Rehab?

The Affordable Care Act (ACA) provisions are binding on privately held insurance firms and the plans offered via the various state-operated marketplaces. As a result, all insurance providers must provide benefits for mental health and drug use disorder therapies that are on par with benefits for physical illness and injury.

However, non-evidence-based opioid treatment services may not be covered by insurance. When therapy is said to be “evidence-based,” it is because solid scientific evidence supports its usefulness.

Scam artists often try to exploit other people’s bad luck to make money, and they will say almost anything to get their victims to give them money. Anyone can say they have a “wonder cure” for addiction, but those claims don’t mean anything if facts don’t back them up.

There are various health insurance policies, and each covers a particular set of expenses related to medical, cognitive functioning, behavioral, and even opioid addiction treatment. Find out from your insurance company or rehabilitation center what is covered.

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Types of Insurance Plans That Can Cover Opioid Rehab

The following are the three primary categories that may be used to classify individual health insurance policies:

Patients with Preferred Provider Organization health insurance policies may choose any provider they like, whether in or outside their network.

Patients enrolled in a Health Maintenance Organization can only see healthcare professionals or treatment facilities within a predetermined group called a “network.” In addition, HMO plans often do not pay for services from out-of-network medical professionals.

Regarding point-of-service plans, members may choose either a health maintenance organization (HMO) or a preferred provider organization (PPO) network for each specific medical procedure.

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Navigating Medicaid & Medicare Coverage for Opioid Addiction Treatment

Medicaid and Medicare: Will They Cover My Opioid Rehab?

The short answer is yes; Medicaid and Medicare both give some degree of coverage for drug use disorder, including addiction to opioids.

Substance abuse treatment, including psychotherapy, medication, and peer-based support groups, are common treatments that Medicaid may cover for adults in certain states.

For those who qualify, the CHIP (Children’s Health Insurance Program) can also offer comprehensive coverage of opioid rehab, among other mental disorders and SUDs. Visit your state’s Medicaid website for mental health services to confirm coverage. In addition, you may read more about the NJ Medicaid program by clicking here if you live in New Jersey.

Medicare’s benefits may be summarized as medical, hospital, and prescription drug coverage.

Services obtained under inpatient care are covered by Medicare Part A. Medicare Part B pays for outpatient medical treatment, such as psychotherapy, opioid rehab visits, and diagnostic testing. Medicare Part D provides coverage for the cost of prescription medications.

Some individuals have private insurance policies that offer health coverage via Medicare C, a Medicare Advantage Plan, for example, PPO or HMO. If this describes you, you must check their official website or call to confirm coverage for mental health and drug use disorder services like opioid rehabilitation.

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Coverage & Care Types

What Options Are There for Opioid Treatment?

In the United States, there is a wide range of options for those struggling with substance abuse, and many of these services are covered by standard health insurance plans. In addition, some opioid addiction treatment programs are partially covered by health insurance, but you should verify that their policy covers your chosen facility.

Insurance companies agreements with hospitals and other medical facilities (such as the maximum length of time allowed) vary from plan to plan, just as coverage for physicians and specialists does.

Opioid rehab programs that may be covered by your insurance, depending on the details of your policy, include:

  • Inpatient/residential care.

  • Outpatient care.

  • Medication-assisted therapy (Medically assisted withdrawal and detoxification).

  • Dual diagnosis (treatment for those with both a primary mental health disorder and SUDs like opioid addiction or both).

  • After-care services.

Navigating Your Insurance Benefits

Rolling Hills Recovery Center Offers Insurance-Covered Opioid Rehab

Contact Rolling Hills Recovery Center’s admissions staff to discuss treatment options, payment options, and insurance coverage. The admissions staff can help you check your insurance plan for coverage of opioid treatment and make the necessary calls on your behalf. In addition, we can assist you with both services—verifying your insurance coverage and obtaining essential pre-approvals.

They will compile a summary of your insurance’s benefits and any potential gaps in coverage, allowing you to predict your out-of-pocket expenses more accurately.

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Written By:

Geoffrey Andaria

Geoffrey Andaria mental health writer at rolling hills recovery center
Rolling Hills Recovery Center

Mental Health Writer

About Author:

Geoffrey Andaria is an experienced mental health content writer and editor. With a B.A. in English and Journalism, Geoffrey is highly educated in freelance articles and research. Having taken courses on social work, Geoffrey is adamant about providing valuable and educational information to individuals affected by mental health and the disease of addiction.

Medically Reviewed By:

Dr. Carl Williams Ph.D., LCADC

Carl Williams, medical content reviewer at rolling hills recovery center
Rolling Hills Recovery Center

Expert Contributor

About Reviewer:

Dr. Williams presently serves on the board of Directors for two non-profit service organizations. He holds a Master’s degree in Human Services from Lincoln University, Philadelphia, Pa, and a Ph.D. with a concentration in Clinical Psychology from Union Institute and University. In Cincinnati, Ohio. He is licensed to practice addictions counseling in both New Jersey and Connecticut and has a pending application as a practicing Psychologist in New Jersey.

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