Rehab Centers that Accept Anthem Insurance

Figuring out how to pay for addiction treatment can feel overwhelming, especially when you’re already dealing with physical and psychological symptoms. While your insurance plan may cover some aspects of drug and alcohol rehab, it depends on how it’s set up.

This guide explains how Anthem rehab coverage works and offers tips to help you verify your benefits. The good news is that the company may cover both in-network and out-of-network care, making treatment more accessible. Your preferred rehab can help you determine if there are additional requirements related to medical necessity, prior authorizations or length-of-stay reviews.

Some Anthem plans cover drug and alcohol treatment, but the extent of the coverage depends on your plan type and design.

Coverage usually depends on:

• Network status. In-network care is typically more affordable, but Anthem may cover out-of-network services at a higher cost.
• Plan type. Anthem offers several plan types, including HMO (health maintenance organization), PPO (preferred provider organization), EPO (exclusive provider organization) and POS (point-of-service). Each one works differently.
• Prior-authorization requirements. Your plan may require prior authorization for some services.
• Medical necessity. Anthem may ask the rehab to prove that the services you’re receiving are medically necessary.
• Cost-sharing requirements. Many plans have deductibles, coinsurance and/or co-pays, which all affect your out-of-pocket costs.

Out-of-network coverage can help you access addiction treatment when there aren’t any in-network options that meet your needs. While out-of-network care often costs more, Anthem coverage may reduce your overall expenses.

Like other insurers, Anthem typically offers behavioral health benefits, which may include treatment for substance use disorders. Out-of-pocket costs often vary based on whether a service is classified as inpatient or outpatient. Inpatient care requires you to stay at a hospital or a residential rehab facility, while outpatient care involves attending treatment sessions at clinics, rehab centers, therapy offices and other community settings.

Depending on what type of plan you have, Anthem might cover these addiction treatment services:

• Supervised medical detox
• Therapy and counseling
• Inpatient or residential rehab
• Medication-assisted treatment
• Aftercare/continuing support

Federal parity laws, such as the Mental Health Parity and Addiction Equity Act, also play a role in determining coverage. Parity means insurance companies must treat mental health services and medical services equally. They can’t place restrictions on addiction treatment if they don’t have the same restrictions for medical care, such as physical exams, X-rays and surgery.

Understanding your rehab coverage can help you make treatment decisions with confidence. Everyone has different needs, so it’s common for people with substance use disorders to require multiple levels of support during the recovery journey. Anthem may cover some of these rehab components depending on your clinical needs and plan details.

Medical Detox

Medical detox, which involves managing withdrawal symptoms under the supervision of experienced professionals, is often the first step. Your plan may cover detox, but it’s common for Anthem to require prior authorization or complete a medical necessity review before approving this service. Some plans also require length-of-stay reviews to determine whether you still this level of care.

Inpatient or Residential Rehab

Inpatient rehab offers 24/7 structure and supervision. You live at the facility while receiving therapy and other supportive services. This level of care is usually more expensive, so Anthem often requires prior authorization before you begin treatment.

It’s also common for the company to approve coverage in stages. This involves ongoing reviews to determine whether your current level of care is still medically necessary.

Medication-Assisted Treatment (MAT)

Opioids are strong painkillers that can cause sedation and euphoria, so they have a high potential for addiction. Medication-assisted treatment may help reduce opioid cravings and prevent relapse. MAT combines medications with behavioral therapies, creating a two-pronged approach.

Your MAT coverage may be split between your behavioral health and pharmacy benefits. Behavioral health benefits typically cover provider visits, while pharmacy benefits are for medications. Anthem may also require prior authorization or limit coverage to medications on its formulary (list of approved drugs).

Therapy and Counseling

Therapy is one of the most important parts of substance use disorder treatment.

Anthem rehab coverage may include:

• One-on-one sessions (individual therapy)
• Group counseling
• Evidence-based approaches, such as cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT)

The services are usually billed under a plan’s behavioral health services. It’s also common to have co-pays or coinsurance for each one.

Dual Diagnosis Support

Not all rehab centers offer standalone mental health treatment, but they may offer integrated care for any individual with a dual diagnosis. Also known as co-occurring disorders, dual diagnosis is when you have a substance use disorder and at least one other mental health condition.

Examples of co-occurring disorders include:

• Anxiety
• Bipolar disorder
• Borderline personality disorder
• Depression
• Post-traumatic stress disorder (PTSD)
• Schizophrenia

Anthem may cover dual diagnosis support under your behavioral health benefits. Services are typically reviewed for medical necessity.

Aftercare and Continuing Support

Aftercare often includes outpatient therapy, relapse prevention planning and peer recovery groups. Continuing care supports you in your recovery journey.

Coverage for aftercare varies widely. Some services are billed separately, while others are considered part of a broader rehab program. Verifying what’s covered can help you avoid unexpected out-of-pocket expenses.

In-network providers have agreed to accept Anthem’s negotiated rates. This usually results in simpler billing and lower out-of-pocket costs.

Out-of-network providers don’t have contracts with Anthem, so they don’t have to accept the company’s negotiated rates. Even if your plan covers out-of-network care, you may have higher out-of-pocket costs, such as a separate deductible or a larger coinsurance percentage. Depending on state law and your situation, you may even be subject to balance billing, which involves the difference between what’s billed and what your insurer covers.

It’s common for multiple providers to be involved in one person’s substance use disorder treatment plan. Make sure you confirm who will bill for each service to make it easier to estimate your total out-of-pocket costs.

Each plan has several moving parts that can affect your out-of-pocket costs, including:

• Deductible: Your deductible is the amount you pay before Anthem starts paying for your care.
• Coinsurance: This is a percentage of the approved amount that you must pay for a service. For example, if your plan has an 80/20 split, you have to pay 20%.
• Co-pay: A co-pay is a flat fee, such as $25 for each therapy session or $10 for a generic medication.
• Length of stay: Longer treatment duration may increase your out-of-pocket costs.
• Level of care. Inpatient/residential treatment usually costs more than outpatient care.
• Medication costs. If you need MAT, you may have additional costs for prescription medications.

Timing also matters. If you start your treatment at the beginning of the plan year, you may have to pay your full deductible, increasing your upfront costs.

Anthem offers several plan types, and each one affects your coverage. Health maintenance organizations (HMOs) require referrals from a primary care provider, and they don’t cover out-of-network care unless it’s an emergency. Point-of-service (POS) plans also require referrals, but they typically cover out-of-network care at a higher cost, making them slightly more flexible than HMOs.

Exclusive provider organizations (EPOs) don’t require referrals, but there’s no coverage for nonemergency care delivered by out-of-network providers. Preferred provider organizations (PPOs) are the most flexible. You don’t need a referral, and you can typically get some coverage for out-of-network care.

DIY Verification Steps (Member)

You can verify your benefits by following these steps:

1. Contact Member Services. The number should be on the back of your ID card.
2. Ask if your chosen rehab is in-network or out-of-network with your plan.
3. Determine if you need prior authorization.
4. Find out if you have to pay a deductible, coinsurance or co-pays.
5. Verify any limits to your coverage, such as number of days/visits or length-of-stay reviews.

Fastest Option: Let a Rehab Verify for You

Asking a rehab to verify your benefits takes the guesswork out of the process. Generally, you just need to provide your plan name and policy number. A representative can verify network status and provide an estimate of your out-of-pocket costs.

If Anthem denies or limits your coverage, contact the company and:

• Determine the reason for the denial.
• Ask about the appeals process.
• Obtain a list of required documentation.
• Request a peer-to-peer or clinical review.

You can also ask about a single-case agreement (SCA). These agreements allow you to receive out-of-network care at in-network rates. Anthem isn’t obligated to approve an SCA, but they may if you can demonstrate that an out-of-network rehab is the only one that can meet your needs.

Seeking help requires courage, but the good news is that you’re not alone. Help.org can help you find a rehab that meets your clinical needs and works with your Anthem rehab coverage.

Fill out the online form or call us today to get help verifying your benefits. We’ll need your date of birth, member ID and group number.