Rehab Centers that Accept Ambetter Insurance

Having insurance can make addiction treatment more affordable, and many Ambetter policies provide some type of coverage for both inpatient and outpatient substance use treatment. How much is covered can vary based on your policy type, medical necessity and network status.

Determining whether your insurance benefits will cover all or part of your rehab program doesn’t have to be complicated. Find out how Ambetter benefits work for substance use treatment and how you can verify coverage.

Ambetter has many plans that cover drug and alcohol rehab. However, how much your policy covers and how much you’ll pay out of pocket may vary based on several factors:

• Plan type (HMO, PPO, EPO, POS). Your plan type impacts whether out-of-network benefits are available and whether you need a referral before starting treatment.
• Network status. Ambetter generally offers better coverage for in-network rehab programs. However, you may be able to get out-of-network coverage, especially if you’re experiencing a medical emergency or have received a prior authorization from the insurance company.
• Medical necessity. Some policies may require proof that a particular type of treatment is medically necessary for it to be covered. They might cover some services, such as detox and counseling, but they may not cover amenities, such as acupuncture or Reiki.
• Cost-sharing. Some Ambetter plans pay for substance abuse treatment after you’ve met your deductible, and you may still be responsible for other cost-sharing, such as coinsurance.

Substance abuse treatment generally falls under behavioral health, which is divided into inpatient and outpatient care for insurance purposes. Federal guidelines require insurance providers to limit discriminatory restrictions when providing benefits. Some Ambetter plans may cover detox, inpatient treatment, therapy, medication-assisted treatment and/or aftercare support, but the exact details depend on your plan and policy type.

Addiction treatment is personal, and your care plan should be tailored to your unique needs. Ambetter policies may have different coverage for the specific levels of care.

Medical Detox

Ambetter plans generally cover medically necessary detox services, but that may depend on the level of care required, the facility’s location and the length of stay. You may need preauthorization from the insurance provider before starting treatment.

Inpatient or Residential Rehab

Residential substance use programs can be helpful for those who need structured support and 24/7 care. Ambetter policies typically cover inpatient treatment, but the amount covered can vary significantly based on whether the facility is in- or out-of-network. Periodic length-of-stay reviews are also common.

Medication-Assisted Treatment (MAT)

Rehab programs often offer medication-assisted treatment as a way to make withdrawal more manageable, but this can be a fuzzy area for insurance providers. Some Ambetter plans may cover medication-assisted treatment as part of a rehab program, but it might be split between medical and pharmacy benefits. Depending on the medications used, the insurance company may want a prior authorization or have formulary requirements.

Therapy and Counseling

Therapy and counseling services are commonly covered under many Ambetter plans. However, there may be differences depending on whether the therapy occurs during an inpatient stay or is considered an office visit.

Dual Diagnosis Support

It’s common for addiction to occur alongside mental health disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). Having a substance use disorder and a mental health condition at the same time is called a dual diagnosis.

Because rehab programs focus on helping clients with substance use issues, many don’t offer standalone mental health treatment. However, a program may offer dual-diagnosis support, and Ambetter may include this under behavioral health coverage.

Aftercare and Continuing Support

Many rehab programs offer aftercare to provide continued support to clients who’ve graduated. Ambetter may cover some step-down services, depending on the policy type, network status and whether it’s included in the rehab’s main program.

Much of whether Ambetter covers drug and alcohol rehab, and how much, depends on whether the program is in-network or out-of-network. If it’s in-network, the facility has negotiated specific rates with the insurance provider, and you’ll have a lower cost share as a result. When a program is out-of-network, insurance may cover a small portion of treatment or provide no coverage at all, depending on the policy.

Even if you’re attending an in-network rehab, some services, such as therapy, may be provided by out-of-network providers. It’s important to verify the network status of all providers to ensure you have an accurate understanding of how much the program may cost and prevent surprise bills.

Depending on your specific policy, substance abuse treatment may be completely covered, or you may be responsible for a share of the amount, known as your out-of-pocket costs.

This can depend on:

• Cost-sharing. This includes your co-pay, coinsurance, deductible and out-of-pocket maximum.
• Admission timing. If you’re at the end of your benefit period, you may have already met your deductible for the year, which can decrease costs. However, if treatment rolls over into the new year, it could reset those limits.
• Length of stay. In general, the longer you stay in treatment, the more services you have and the higher the cost.

Your Summary of Benefits and Coverage statement can help you determine how much you could pay out of pocket for rehab.

Most Ambetter plans are purchased through the Health Insurance Marketplace and are HMOs or EPOs. HMOs and EPOs are similar in that they typically only provide coverage for in-network providers or emergency care. However, EPOs are slightly more flexible because you don’t usually need a referral to see a specialist.

To determine what kind of plan you have, check your insurance card. It will usually give you the plan type and other important information, such as your member ID and policy number. You can also find your plan type in the Ambetter member portal or on your Summary of Benefits and Coverage statement.

To verify Ambetter benefits for drug and alcohol rehab, you can call member services directly or ask the rehab program to verify your insurance.

DIY Verification Steps (Member)

1. Call Ambetter’s member services number on the back of the card.
2. Ask if the rehab is in-network or out-of-network for your Ambetter plan.
3. Confirm authorization requirements for your level of care.
4. Confirm the amount of your deductible, coinsurance, co-pays and out-of-pocket max.
5. Ask whether there are any limits or exceptions, such as medical necessity or preauthorization requirements.

Fastest Option: Let a Rehab Verify for You

The fastest way to verify your insurance is to call the rehab and ask whether it’s in-network for your policy. You’ll need your Ambetter policy number and member ID. While the insurance company makes the final decision about coverage, this verification step can help you get a better idea of what’s likely to be covered and what you may pay out of pocket.

If your coverage gets denied, the first step is to find out why. The insurance company has to provide you with a reason, and there’s often an appeals process you can use if you believe the denial was unwarranted.

In some cases, you can request the required documentation list and ask for a peer-to-peer or clinical review. If your benefits were denied because the rehab is out-of-network, it’s worth asking about a single-case agreement. Ambetter may agree to negotiate rates with the rehab on a one-time basis.

If you’re considering rehab but need to know whether your Ambetter policy covers the cost, Help.org can help. Grab your insurance card and call us to learn more about your benefits and determine which rehabs fit your needs and your insurance coverage.