When Does Insurance Actually Cover Drug Detox? (A Guide)

Addiction is a serious health problem, commonly classified as a mental illness or brain disease, that warrants professional medical treatment. Though many people try to quit on their own once they realize an addiction disorder has developed, it can be much more difficult than imagined. The combination of intense cravings and withdrawal symptoms means that the relapse rate of those addicted to a substance is 40-60 percent. However, professional addiction treatment can significantly reduce the chance of relapse and make the entire process easier.

What Is Detox?

Doctor explaining to patient about detox from substances

The first step in many addiction treatment programs is detoxification – the process of letting the addictive substance leave the body and enduring withdrawal symptoms as the body and brain go back to a “normal” state. Detox can be very intense and unpleasant. When it comes to certain intoxicants like alcohol and some prescription medications, withdrawal symptoms can be dangerous. The knowledge of these facts can keep a lot of addicted persons from even attempting to get clean.

To help people get through this difficult process, many hospitals and specialized addiction treatment centers offer medically assisted detox. This service allows clients to stay in a hospital setting where they will be monitored and treated for any withdrawal symptoms. Most common withdrawal symptoms can be treated with simple, nonaddictive medications, making the process much more comfortable. The goal of medically assisted detox is to make the client as comfortable as possible for the duration of the worst of the withdrawal symptoms. This typically lasts a few days to a week.

Unfortunately, a stay in a hospital for this long can be very expensive without insurance coverage. Although most insurance policies cover addiction treatment, it may not cover every aspect of treatment entirely. Inpatient or outpatient rehabilitation is often covered, but this can be considered separate from detox, especially medically assisted detox programs. Complications like this contribute to the fact that only a little over half of the people who sought treatment for an addiction disorder received any treatment in 2014, according to the National Survey on Drug Use and Health.

Policies of Common Insurance Companies

The passing of the Affordable Care Act declared substance abuse and addiction disorder treatment one of the 10 elements of essential health benefits, meaning that all insurance policies offered on the open exchange market must cover basic addiction treatment. However, whether this includes a professional detox service depends on the individual policies within each company.

These are some of the most common health insurance companies and their policies on detox treatment:

  • Aetna: Generally, Aetna covers detox services as long as the appropriate type of detox is pursued based on the American Society of Addiction Medicine guidelines. Type and length of care covered are determined on a case-by-case basis.
  • Anthem: Many types of detox service are covered, including both inpatient and outpatient options. Inpatient acute withdrawal and residential treatment withdrawal are named in their policies as well as office-based outpatient detox, extended onsite monitoring outpatient detox, and outpatient addiction treatment with medication for opioid dependency.
  • Cigna: Most policies appear to cover both inpatient and outpatient detox treatment, though a professional recommendation for one type or the other may be required.
  • Humana: Generally, Humana covers detox treatment based on the guidelines provided by the American Psychiatric Association, but requires a referral from a doctor on what type is needed.
  • Kaiser Permanente: Kaiser covers inpatient addiction services lasting 1-6 weeks based on the severity of the addiction, and either long-term or intensive outpatient treatment, with the long-term lasting up to a year or more. This doesn’t mention detox treatment outright, though the company website lists detox and withdrawal as part of the recovery process.

Even if you have plans under one of these companies, there’s no guarantee that they will cover the detox treatment you need. It’s essential that you speak with both your doctor and a representative from your insurance company to confirm that you will be covered. It’s the customer’s responsibility to make sure that a service they’re using is covered, and if you go ahead and use a non-covered service without checking, you’ll be expected to pay the full amount of the bill.

Keep in mind that 19 out of 50 states still have not accepted the benefits offered by the Affordable Care Act and therefore the plans offered within their borders may not be required to cover any addiction treatment. Check your state’s individual status on the matter and its own laws on health insurance for more information.

Medical Necessity

In some cases, the process can be more complicated. Some insurance policies only cover some types of detox treatment. Other times, the insurance company will want to pick a method of treatment for you based on your current medical need.

Factors involved in this decision include:

  • Severity of withdrawal symptoms
  • Options available in the treatment facility the patient is referred to
  • Intensity of the service requested
  • Length of stay needed
  • Co-occurring disorders
  • Personal circumstances

In spite of extended coverage mandated by the Affordable Care Act, insurance companies still have the right to require proof that professional treatment of a health problem is a “medical necessity” – that is, there’s a substantial risk to the patient if the person does not get the treatment being sought. This typically means that a doctor’s referral will be required in order to get covered.

Your insurance company may interview you in order to get the answers to these questions. In order to get the most appropriate treatment covered, make sure to be honest about your symptoms and list all the factors you can think of that might affect the treatment program. For example, if you have children and can’t afford childcare, outpatient treatment may be deemed best for you. On the other hand, if previous outpatient treatment attempts failed, a company may only agree to cover an inpatient program.

The status of your determined medical necessity may change in the middle of your treatment along with your circumstances. For example, if withdrawal symptoms don’t diminish after a week, it may be deemed medically necessary for the length of your stay at a treatment facility to be extended. On the other hand, if you appear to respond to inpatient treatment quickly, you may be switched to a less intensive (and expensive) outpatient program.

Options for Those Without Insurance Coverage

If your insurance policy does not cover detox treatments, don’t despair. There are options for free services or treatment centers that charge on a sliding scale. This is also helpful for the millions of Americans still without any health insurance.

All states in the US and the District of Columbia have state-funded rehab services for low-income individuals with addiction disorders. The services offered and the requirements to be accepted into such a program vary with each state, so you’ll need to contact the program itself to see if you can be considered. The Substance Abuse and Mental Health Services Administration has a directory containing contact information for each agency in each state.

Though each agency is different in whom it will accept, anyone can expect to be required to provide proof of residence in the state, proof of income, proof of legal residence in the country, and a medical history including the severity of addiction. Those who are accepted can get free treatment or treatment at a significant discount. The downside to these programs is that they can require a significant wait, as many apply and only so many can be treated by the state at a time. Certain at-risk individuals, such as pregnant women, may be able to skip the line, though that means a longer wait for others.

In addition to state-funded treatment centers, there are also faith-based options across the country. The Salvation Army Adult Rehabilitation Centersand Harbor Light both offer free or discounted detox services in many locations. Other centers cater specifically to the Jewish community or other religious faiths. Keep in mind that not all of these facilities offer full services and may only provide 12-Step meetings and counseling. Again, space may be limited, though the application process is usually less intense.

Some private treatment facilities also offer “scholarships” for low-income individuals who need addiction treatment. These may also be offered through organizations dedicated to combating addiction problems and helping those affected. If money is an issue, be sure to ask any private treatment center about grants for those in need.

If paying up front is a problem, many of the addiction and detox centers across the country offer financing options. There are even loan companies specifically dedicated to providing financing for those looking for addiction treatment. If you can prove that you’ll be able to pay back the loan after treatment is completed, you should be able to get a loan or a payment plan that will allow you to receive the care you need.

Verify Your Insurance Benefits

The quick and easy benefits verification form below is private and will help you understand what your plan covers in terms of substance abuse treatment and whether detox is included.