Is Heroin Rehab & Treatment Covered by Insurance?

Written by: Editorial Staff

Last updated on June 7, 2021

Funding heroin addiction treatment can be challenging, despite the fact that there are financing options designed to make it more affordable and more easily accessible to treatment-seeking individuals.¹ 

There are various valuable resources available to treatment-seeking individuals who cannot afford to pay for heroin addiction treatment: from free and low-cost facilities across the U.S. to heroin addiction treatment centers that accept Medicaid and private insurance, in which case insurance may cover some or the full cost of heroin addiction treatment.¹

However, that does not make understanding the costs of heroin addiction treatment and figuring out the best way to pay for it any less complex and frustrating. Many of the resources available are not easy to navigate, which is why we shed some light on insurance coverage for mental health and substance abuse services.¹ 

Easier Access and Higher Heroin Treatment Insurance Coverage

Despite the growing number of rehab programs specializing in heroin addiction treatment available nationwide (it is currently estimated that there are over 14,500 specialized public and private drug treatment facilities provide these nationwide), not enough treatment-seeking individuals end up seeking treatment.² 

According to a report issued in 2015 report, the need for substance abuse treatment is extremely high, but only 10% of individuals in the U.S. are actually receiving it and the cost and lack of insurance coverage may have a major impact on this grim state of affairs.³

Yet, ongoing efforts are being made nationwide to improve this state of affairs and make the cost of rehab more affordable and heroin addiction treatment more easily accessible.¹

A large portion of drug treatment in the U.S. is funded by local, State, and Federal governments. Private and employer-subsidized health plans may also provide coverage for addiction treatment and associated complications and medical consequences.²

Rehabilitation is now considered an essential health benefit. It is covered under the Affordable Care Act (ACA) which has enabled access to mental health and substance use disorder services, including behavioral health treatment, to more individuals.⁴ 

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 has also had a major impact on insurance coverage for mental health and substance abuse treatment. This federal law prohibits health insurance issuers and group health care service plans from discriminating between coverage offered for mental illness, serious mental illness, substance abuse, and other physical health disorders and diseases. This means that a person struggling with mental illnesses or substance abuse is entitled to the same benefits as individuals suffering from other physical disorders and diseases.⁴

There are still some obstacles to overcome: managed care has had a negative effect on treatment length and America continues to face a chronic lack of or insufficient coverage for substance abuse treatment which has reduced the number of programs in operation or limited their effectiveness.²

What Levels of Care in Drug Rehab Are Covered by Insurance?

The intensity and duration of treatment for heroin and drug abuse may vary depending on a range of factors:⁵

• The particular substance(s) of abuse
• Duration of use
• The patient’s medical and emotional condition.

It may be medically necessary for a treatment-seeking patient to receive detoxification and/or rehabilitation as a hospital inpatient, in which case care coverage will be available. 

Outpatient treatment services may also be covered for hospital patients discharged from an inpatient department for the treatment of substance abuse. For instance, these patients may require care, but may not meet the criteria for duration or intensity of services provided during inpatient treatment.⁵

Coverage of inpatient and outpatient hospital services is available if these services are reasonable and medically necessary. For inpatient patients, additional requirements apply in terms of level of care and length of treatment.⁵

There are different levels of care provided during heroin addiction treatment, depending on the intensity, duration, and type of services offered:⁶

• Detoxification and medically managed withdrawal, typically the first stage of treatment
• Partial hospitalization program (PHP)
• Inpatient program
• Low-intensity outpatient program 
• Intensive outpatient program (IOP)
• Short-term residential treatment: hospital-based inpatient treatment phase followed by extended outpatient therapy
• Long-term residential treatment: highly structured, customizable treatment, 24/7 care in a non-hospital setting
• Individualized drug counseling
• Group counseling
• Specialized intervention and treatment for vulnerable populations

What Is Not Covered by Insurance?

The benefits provided by funding streams from public and private health insurance depend on whether or not the services are facility-based and the level or setting of care provided.⁷

When it comes to heroin addiction treatment, coverage and reimbursement may depend on two factors:⁷

• Whether a service is considered to be a medical service or a substance abuse treatment service.
• Whether a service is facility-based. Some therapies/services are provided by rehab but are not covered by insurance. This applies to all services not categorized as a medical necessity.

How Can I Find Out About My Insurance Policy Coverage? 

The first step is to reach out to your insurance provider to check your policy coverage. Alternatively, you can learn more about your coverage and payment options for substance abuse treatment in a more confidential manner through specialized heroin addiction treatment hotlines.

By contacting Heroin.net or American Addiction Centers, you can gather all the important information about your coverage and available treatment options. AAC is in network with major insurance providers and can verify your insurance for free. Speak to our admissions navigators for more information. 

Frequently Asked Question

What Is the Difference Between In-Network and out of Network Rehab?

When discussing the difference between in-network and out-of-network rehab, it is important to emphasize the following key differences:⁸

• Differences in coverage
• Levels of care
• Other amenities

What Are the Other Ways to Pay for Treatment?

To pay for heroin treatment, uninsured or underinsured treatment-seekers and their families have the following options at their disposal:⁹

• Payment plan offered at some treatment facilities
• Credit options and loans 
• Friends and family support
• Crowdsourcing

How Much Does Rehab Cost in Out of Network Centers?

The cost of rehab in rehab facilities that are not in your network is typically higher than in-network rehab.⁸ The precise cost will depend on the facility, type of care, and other factors unique to your specific needs. 

How to Get Into Rehab Without Insurance?

Help for individuals battling heroin addiction with no insurance is available. For individuals who do not have insurance, there are options to seek public assistance or government-funded drug addiction treatment by applying for federal aid which is distributed to the states.³ 

Additionally, states have rehabilitation funding available to uninsured or underinsured treatment-seekers looking for heroin treatment centers or programs, and the same goes for funding set aside by local governments.³

Does Medicare Cover Heroin Rehab Center?

Medicare does cover the cost of a stay in a heroin rehab center in an outpatient or inpatient setting as long as the services provided to treatment-seekers are considered reasonable and medically necessary and that the provider is Medicare-approved, as long as the treatment plan is set up by the provider:¹⁰

• Partial hospitalization program (PHP)
• Substance abuse treatment by suppliers of services
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) services
• Medications used to treat opioid dependence
• Inpatient and outpatient treatment

Inpatient Treatment

Medicare covers:¹⁰

• Inpatient treatment would be covered if reasonable and necessary.
• Professional services provided during that care would be paid either as part of the inpatient stay or separately, to the professional billing for the provided services if separate from the inpatient stay.
• The cost of medication provided as part of inpatient treatment is included in the cost and not paid separately.

Outpatient Treatment

Medicare provides:¹⁰

• Coverage of outpatient treatment depending on the treatment provider.
• Coverage of certain services: Medicare does not recognize substance abuse treatment facilities as an independent provider type, which is why not all services included would be covered by Medicare.
• Coverage and payment on a service by service basis for Medicare-recognized services.
• Coverage for medications used in an outpatient setting may also be covered provided they are not normally self-administered.

Which Insurance Offers the Longest Rehab in the Coverage?

Although a high cost of heroin addiction treatment does not guarantee the effectiveness of the treatment, it may mean that the treatment will be more comprehensive, last longer, and include a broader range of services. This may also mean it will be better adapted to the treatment-seeking individual’s needs.² 

Part of the reason why the duration of rehab is so important is that treatment needs to last a sufficient amount of time in order to properly respond to a treatment-seeking individual’s needs, especially in the case of chronic heroin users.¹¹

Are Luxury Rehabs Covered by Insurance?

A comprehensive heroin addiction treatment plan consists of a supervised, medication-assisted detoxification stage and tailored rehabilitation process with aftercare which incorporates counseling and behavioral therapy.¹¹ Cost of treatment at a luxury rehab is high, but so is the level of care and comfort provided to recovering individuals in these facilities. Insurance may cover a portion of the cost of luxury rehabs.¹²

Depending on the specific circumstances a person is in, they may require outpatient treatment, or an intensive 28-day rehab.¹¹ They may prefer to be accommodated at a rehab facility in the proximity of their family, provided that their insurance covers the cost of treatment there.¹²

What Questions Should I Ask My Insurance About Rehab Treatment?

The key question for your insurance provider is whether they cover:¹²

• Behavioral health treatment (psychotherapy and counseling).
• Mental and behavioral health inpatient services.
• Substance use disorder (SUD) treatment.

Benefits may also depend on your specific coverage and your state.¹²

How to Find Heroin Treatment?

Below are the key principles of effective treatment, which are also considerations to bear in mind when looking for rehab:¹¹

• Addiction is a complex, chronic, relapsing but treatable disease that affects brain function and behavior, especially if not addressed in a timely manner.
• No single treatment is appropriate for everyone. Matching treatment to an individual’s particular problems and needs is critical to their ultimate success and ability to stay in recovery and lead a productive, healthy life.
• Treatment needs to be readily available as soon as the person is ready to enter treatment.
• Treatment can be effective even if it is not voluntary.
• Effective treatment takes a whole-person approach, and needs to address all the needs of a person, not just their drug abuse.
• Remaining in treatment for an adequate period of time is critical. Recovery is a long-term process and may need to take place in stages, as it often requires multiple episodes of treatment.
• Behavioral therapies are necessary to help a person find motivation to change and maintain abstinence through positive skill building, enhanced problem-solving, promotion of constructive and rewarding activities, and fostering better interpersonal relationships.
• Medications combined with counseling and other behavioral therapies are considered to be essential to effective treatment. 
• Medication-assisted detoxification is an important first stage of addiction treatment.
• Continual assessment of treatment plans is necessary. Modifying treatment as necessary is needed for the purpose of better accommodating the recovering individuals’ changing needs. 
• Incorporating treatment of co-occurring mental disorders into the treatment plan. 
• Monitoring drug use and assessing risks of relapse during treatment must be continuous.  
• Treatment programs should test patients for infectious or other diseases so clients would be referred to appropriate treatment if necessary.  

American Addiction Centers has treatment facilities across the nation where treatment-seekers can receive individualized care and advanced technology is employed to help make treatment more effective and the overall experience more comfortable. Contact our helpline to discuss your heroin treatment options and verify your insurance coverage and other methods of covering treatment costs.

Here at American Addiction Centers (AAC), we can run a verification check for you for free and without informing your insurance carrier, if this is what you prefer. Our conversation with you will be absolutely confidential. AAC is in-network with major insurance providers which provide coverage for substance abuse treatment:

Let’s verify your coverage for Heroin treatment at an American Addiction Centers location. Your information is always confidential.

Sources:

1. FindTreatment.gov. (2019). Paying for Treatment: Understanding the Cost of Treatment.
2. National Institute on Drug Abuse. (2020). Drug Addiction Treatment in the United States. 
3. Substance Abuse and Mental Health Services Administration. (2016). America’s Need for and Receipt of Substance Use Treatment in 2015.
4. National Conference of State Legislatures. (2015). Mental Health Benefits: State Laws Mandating or Regulating.
5. Centers for Medicare & Medicaid Services. (2021). National Coverage Determination (NCD) for Treatment of Drug Abuse (Chemical Dependency) (130.6).
6. National Institute on Drug Abuse. (2020). Types of Treatment Programs. 
7. Substance Abuse and Mental Health Services Administration. (2015). TIP 45: Detoxification and Substance Abuse Treatment. 
8. HealthCare.gov. (2021). Out-of-Network Coinsurance. 
9. Substance Abuse and Mental Health Services Administration: Center for Behavioral Health Statistics and Quality. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings.
10. Department of Health and Human Services: Centers for Medicare & Medicaid Services. (2019). Medicare Coverage of Substance Abuse Services. 
11. National Institute on Drug Abuse. (2020). Principles of Effective Treatment.
12. HealthCare.gov. (2021). Mental Health & Substance Abuse Coverage.