How to Pay for Drug Rehab: EmblemHealth / GHI Insurance 

Addiction can take an exhausting mental and emotional toll on you and your loved ones. It’s an illness that can have devastating consequences for families. What’s an even bigger struggle is the high cost of addiction treatment. Because of how expensive treatment is, many families don’t seek help for their loved ones. On top of this, finding the right treatment facility and plan can be an overwhelming task. All the while, the addiction continues to wreak havoc on your life. If you’re looking into addiction treatment, you’ll want to find out from your insurance provider what treatments are covered with your particular health plan.

One of the most relieving aspects of coverage under Emblem is that the company tends to cover at least a portion of the outpatient treatment cost without requiring prior approval, at least as long as you seek treatment at an in-network facility. You do tend to need prior approval before receiving coverage for an inpatient stay. 

However, the specific coverage of your policy will vary. It can be hard to decipher the language and understand what services and length of time that your Emblem health plan covers. The benefits of your policy are variable based on many different factors, so talking to a knowledgeable insurance representative or drug counselor can help.

Emblem offers drug addiction treatment coverage. If your policy only covers in-network providers, you’ll need to find a treatment center that is a partner with Emblem Health. For those with out-of-network policies, you have a lot more freedom in choosing your treatment center. Always double-check that your insurance policy will cover the cost before you commit to a facility, though.

Emblem is a non-profit insurance company held by private ownership. Behavioral health services covered vary depending on the plan. The Affordable Care Act stipulates that behavioral health services must be covered at the same rates as other medical services.

Questions to Ask About Your Insurance Policy

When you’re researching addiction treatment for a loved one or yourself, you must understand the specifics of your insurance policy. Unless you’re an expert in insurance and legal documentation, you’ll probably struggle to understand the jargon in your on-paper policy. The fastest way to get important information is to speak with an insurance representative.

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These are some of the questions that you’ll want to ask to get a better understanding of how your insurance coverage will affect your treatment options:

  • How much will I be paying in out-of-pocket costs and deductibles?
  • What specific services are covered?
  • What are the specific services not covered?
  • How much freedom do I have in choosing whether my provider is in-network or out-of-network?
  • How many my policy covers days or weeks of substance abuse treatment?
  • Will I pay more out-of-pocket for an inpatient stay than an outpatient stay?

Outpatient Treatment Limits Through Emblem

Emblem insurance plans tend to limit outpatient treatment plans to sixty visits per individual per the calendar year. With 365 days in a year, that’s around one outpatient visit per week. This is a reasonably standard outpatient treatment. However, when you’re first recovering from addiction, you may need inpatient care or a more intensive outpatient program.

Partial hospitalization programs and intensive outpatient programs are both forms of addiction treatment that involve meeting several times a week for the treatment duration. If you start your recovery early in the calendar year, this can make you hit the sixty visit limit fast. The first sixty visits tend to be one hundred percent covered by the insurance company, but after that, you have to shoulder the cost of your additional sessions.

Celebrities and business executives often favor specialty treatment plans at luxury and exclusive facilities. However, the majority of these private centers are not covered through an Emblem health insurance policy. Should you stay in one of these places, you’ll have to pay for the treatment yourself.

If your healthcare provider determines that you should be treated at a residential inpatient center, you’ll need to receive direct approval from Emblem. The vast majority of Emblem plans are not designed to cover inpatient stays, so you will need to pay out of pocket.

Emblem Plans

Consumers can choose from five different plan structures provided by Emblem. The co-pays, deductibles, and coverage amounts all vary from plan to plan.

Basic Plan

The Basic plan comes with the most affordable premiums, but it also has the highest deductible. Each individual in the program is subject to a $6,850 deductible, with the cap for a family being $13,700. 

The purpose of the plan is to cover individuals at or under age 30, along with individuals who meet specific financial qualifications. Once the deductibles are met, no coinsurance or co-payments are required, and one hundred percent of preventative care costs are covered.

Bronze Plan

This plan comes with an annual deductible of $3,700 per individual that caps out at $7,000 per family. Following the deductibles, there aren’t any co-pays, but there is a 50 percent coinsurance rate. As with the Basic plan, the Bronze plan covers 100 percent of preventative care services.

Silver Plan

With the Silver plan, the annual deductibles for individuals are $2,000 per person with a $4,000 family cap. Following the deductible, the patients will be subject to a flat co-pay of $30, $50, or $150 depending on the policy. All preventative care measures are fully covered. Certain services are subject to coinsurance costs after you’ve met the deductible.

Gold Plan

The premiums for the Gold plan are significantly more than with most of the other options. That’s because the deductible reaches only $600 per person, and the cap for a family is $1,200.

In addition to full coverage of preventative services, the plan also gives you access to AdvantageCare Physicians. You do have to pay coinsurance following the deductible on certain services.

Platinum Plan

The Platinum plan is the one coverage that does not come with an annual deductible. The limit for out-of-pocket costs for individuals is $2,000, and a family will not need to pay more than $4,000 out-of-pocket before having their services covered.

The co-pays under this plan will be a flat fee of $15, $25, or $100. Some selected services require coinsurance. All preventative services are covered, and you also get access to the AdvantageCare Physician network.

Medication-Assisted Treatment

As long as the medication is administered by physicians licensed in opioid addiction treatment, all insurance plans will cover the medication-assisted treatment. Some of the most commonly-used medications are buprenorphine and naloxone. To provide this treatment, a physician must have received authorization by the Drug Enforcement Agency.

Some patients overcoming an addiction to prescription opioids or heroin may benefit from methadone as a short-term treatment. However, methadone does not tend to be covered for long-term periods in the treatment of opioid addiction. Emblem plans will not cover the cost of methadone treatment if it’s being used as a maintenance medication.

Sober Living Homes

Sober living homes are spaces that give transitional housing to people who have completed a treatment program but are easing back into real life. They create safe and sober environments for patients who can’t live on their own yet.

Sober living homes aren’t treatment facilities, so they aren’t covered by Emblem insurance. Still, sober living homes may be a good option for those who need a stepping stone between inpatient and outpatient treatment.