Does My Insurance Cover Detox?

Depending on the substance in use, detoxification is often the first step in the drug abuse recovery process. For this reason, there is obvious concern about whether insurance will pay for detox and to what extent.

Before approaching an insurance company about coverage, some preparation and information gathering can be helpful. Understanding the basics of detox programs and what services are offered can illuminate the process of paying for it with insurance partially or completely, depending on the health insurance plan.

Cold Turkey or Medical Detox?

Detoxification is not considered substance abuse treatment by the Substance Abuse and Mental Health Services Administration. Rather, detox manages severe intoxications and substance withdrawal. Detox in a controlled setting is meant to minimize the physical harm a patient can experience when withdrawing from certain substances. Treatment for a person’s addiction begins after he or she has detoxed from the substance(s).¹

Most substances that are abused have withdrawal symptoms. Heroin, prescription opioids,² benzodiazepines,³ cocaine,⁴ and alcohol⁵ in particular are known for their difficult detox process and sometimes dangerous withdrawal symptoms.

There are different settings in which detox can take place, such as:

• Alone at home, also known as going “cold turkey”.
• Supervised outpatient, which can happen at a doctor’s office.
• Inpatient, which occurs in a hospital, detox center, or rehab facility to allow round-the-clock monitoring of the patient.

When considering which option to pursue, it’s critical to understand that abruptly quitting drugs can precipitate severe withdrawal symptoms. While cold turkey works in some instances, medical detox or medicated detox is often a safer option.

During medical detox, whether inpatient or outpatient, addiction specialists oversee the patient’s natural detoxification process. To make the process comfortable, the attending doctor may provide mild prescription drugs, such as muscle relaxers for cramps.

In addition, staff may provide over-the-counter medications. The detoxing person, if in an inpatient setting, may also receive psychological therapy and will be provided nutritious meals. Overall, medical detox provides a person with a more comfortable detox environment while providing added assurance of physical and psychological safety.

Medicated detox is available at the facilities that offer detox programs depending on the drugs of abuse at issue. It features medication-based substitution therapies (i.e., FDA-approved addiction treatment medications). For example, a person who has been abusing heroin can be put on buprenorphine. This way, the person does not go into full withdrawal but is transitioned to, and stabilized on, a safer drug.

This method helps stop or manage withdrawal symptoms, including reducing or stopping drug cravings. Over time, a person may be weaned off the substitution medication and achieve full detoxification.

Factors Influencing Detox Program Costs & Insurance Coverage

In the scope of addiction treatment from beginning to end, SAMHSA states that covering detox services is more cost effective for insurance providers.¹ For example, if a person’s whole detoxification process isn’t reimbursed by insurance, patients could potentially be released from detox early, which could make the withdrawal process more difficult or even dangerous. If there are medical complications from this early release, the overall cost of the person’s healthcare could increase exponentially.¹

The previous section’s description of detox programs provides insight into the many billables involved. Various factors drive the cost of a detox program, such as:

• Inpatient treatment is likely to be more expensive than outpatient treatment because round-the-clock care is provided and the facility is supporting all the patient’s needs (e.g., housing and meals).
• Length of stay.
• Receiving medications during medicated detox.
• Additional services, such as psychological therapy.
• If it is not the person’s first admission to a drug rehab program, whether health insurance plan limits have been exhausted will factor in.

A person seeking detox, or a loved one who is organizing the person’s admission to a detox program, will initially go through a process of piecing everything together. First, the rehab center will make a recommendation as to the type of detox that is needed to address the person’s specific needs.

Once the person knows what program type and services are needed, the next step is to learn what services the health insurance company will cover.

Understanding Detox Coverage

A drug rehab center can help a patient and/or concerned loved one to navigate a health insurance plan’s coverage terms. They will be one of your best resources when trying to work out these details.

When you come to these conversations, having a copy of your summary plan description (SPD) can be extremely helpful. This document sets forth the insurance company’s coverage terms. Of course, those terms remain open to interpretation, but the SPD provides insight into what services may and may not be covered.

Rehab centers and insurance companies are extremely familiar with the billing side of the recovery process. For instance, the rehab center will know the specific medical codes that are ascribed to different detox services, and the insurance company will know whether they are covered.

That said, it’s not simply a black-and-white process of coverage versus non-coverage of services. Additional issues can arise, such as the insurance company limiting the number of certain treatments or days of treatment.

Once a person is admitted to a detox program and the process is underway, pay close attention to any correspondence from the insurance company. Correspondence like an “Explanation of Benefits” will show important details in writing, such as:

• The specific service that the detox program/rehab program billed to the insurance company.
• The date of service.
• The amount that that the insurance company paid for the service.
• Any balance due that is the responsibility of the patient.

Using insurance to pay for ongoing medical services, in general, is a learning process. Staying in touch with the insurance company can help to avoid any surprises and signal what’s ahead (e.g., a limit, such as number of treatments, being reached).

Insurance companies, in the event of a dispute, provide an appeals process. The hope is that there will not be any need for a dispute resolution, but it’s good to know that one is available.

Does My Insurance Cover Detox Services?

Understandably, a person seeking detox services will question whether insurance will cover it. It’s an obvious question that might not have so obvious an answer.

As discussed, the best practice is to reach out to the insurance company directly or through the selected detox center/drug rehab facility. It’s usually part of a rehab center’s responsibilities to be in contact with insurance companies.

For instance, before a client is admitted to a detox program, the rehab center will typically contact the insurance company for precertification. After admission, the rehab center may need to continually contact the insurance company for a utilization review, so the insurance company knows the insured member continues to meet the requirements for drug treatment coverage.

You can find your member care contact information for a health insurance on the insurance card. Popular insurance companies’ contact information is outlined below:

• United Healthcare provides the public with a “contact us” link by state.
• Wellpoint Group, also known as Anthem, has a “contact us” link on their official website.
• Kaiser Permanente maintains a member services link with contact information by state.
• For Humana, contact information is available on the official site with an additional option to ask a question online.
• To reach Aetna, visit the contact page of their official website.
• For Health Care Service Corp (HCSC), the “contact us” page provides phone numbers for each of the company’s locations in the US.
• American Family provides the public with several different ways to contact a support person with questions or concerns.
• Highmark (Blue Cross/Blue Shield) has customer service information available on their website.
• For Blue Cross/Blue Shield, the official site provides contact.
• Cigna provides a complete contact list on their company website.

The Mental Health Parity and Addiction Equity Act of 2008 requires insurance providers to offer equal coverage for addiction treatment as they do for other medical needs.

At present, the Affordable Care Act (ACA, also known as Obamacare) remains in effect in America. ACA has specifically designated drug abuse treatment services as an essential health benefit, and as such, all ACA plans must provide some level of coverage.

This rule does not apply to all health insurance plans in the United States, but it does apply to all ACA plans, whether they are employment-based, private, or public (e.g., state Medicaid programs).

Paying for detox and other recovery treatments is understandably a concern, but it should never be a barrier to getting help. Insurance companies may not advertise their coverage of drug treatment services, so it’s critical for those in need to seek out this information.

The addiction treatment industry is layered with caring professionals who want to provide exemplary help at every turn. When a person’s goal is recovery, the assistance to get through it—including assistance working with insurance companies—is available.

Verify Your Benefits Today

For more information about how your insurance may cover addiction treatment, fill out the form below.

References:

1. Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment. (2006). Treatment Improvement Protocol (TIP) Series, No. 45. Rockville, MD: Center for Substance Abuse Treatment.
2. MedlinePlus. (2018). Opiate and opioid withdrawal.
3. Petursson, H. (1994). The benzodiazepine withdrawal syndrome. Addiction 89(11), 1455-1459.
4. MedlinePlus. (2019). Cocaine withdrawal.
5. MedlinePlus. (2019). Alcohol withdrawal.