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Understanding Insurance Benefits For Addiction Treatment

Written on June 24, 2021
Understanding Insurance Benefits For Addiction Treatment

Does health insurance cover addiction treatment?

Due to the Affordable Care Act (ACA), health insurance providers are required to cover treatment for substance use disorders and other behavioral health care. The types of treatment and duration of treatment covered can vary depending on your plan. Flatirons Recovery can verify these benefits for you prior to treatment so that you know exactly what is going to be covered.

What are the different kinds of health insurance plans?

Most health insurance plans are either Health Maintenance Organization (HMO) plans or Preferred Provider Organization (PPO) plans. Here is a breakdown of each:


HMO insurance plans generally have lower premiums and lower deductibles than PPO plans. HMO plans allow patients to chose a primary care physician who is in their insurance network. Whenever the patient has a medical need that necessitates specialty care, they must first obtain a referral from their primary care physician. HMO plans generally do not cover out of network services outside of emergency care without a single case agreement (which we will explain below).


PPO plans may be more expensive and have higher deductibles than HMO plans. The main benefit of a PPO plan is that it will allow you to see a specialist in or out of your insurance network without a referral from a primary care physician, and is therefore a more flexible option.

What is the difference between an in network and an out of network provider?

An “in network” provider is a provider who has a direct contract with your insurance company. Most PPO plans and some HMO plans allow you to use what is referred to as an “out of network” provider for addiction treatment services. This is a provider or treatment center that does not contract directly with your insurance provider. Depending on your plan, out of network providers may be available for at the same cost to you as an in network provider, or you may have a separate deductible to meet for out of network services. Because each insurance plan is different, it is helpful to have a treatment center verify exactly what your policy will cover prior to beginning addiction treatment. Our admissions team can do this quickly while you are deciding if our addiction treatment program is the best fit for you. If, after having your benefits verified you decide you prefer a treatment center who is in network with your insurance, you may qualify for what is called a “single case agreement.” This is when your insurance provider considers an out of network treatment center “in network” for your case, based on circumstance. If for whatever reason we are not the right fit for you due to insurance constrictions or any other reason, we are more than happy to help you find placement in another treatment center that will best meet your needs.

The pros and cons of using an out of network addiction treatment provider

There are many things to consider when deciding between an in network and and out of network providers. Staying with an in network provider is likely to be less expensive than an out of network provider. Still, there are numerous benefits to using an out-of-network provider for addiction treatment:

  1. Out of network providers are easier to find. When going out of network, you are likely to find a treatment center with immediate availability who is in the area you wish to be in for your substance use disorder treatment. Though insurance companies say that their networks are extensive, it can sometimes be difficult to find a treatment center with immediate availability if you are using your in network benefits.
  2. Out of network providers can create a curriculum based on their clinical expertise, not on requirements set in place by insurance companies. You are more likely to find a holistic program out of network, because they are not bound to the constraints of their insurance contract. It is more difficult to find an in network provider who can address not only the substance abuse disorder, but also an underlying mental health issue concurrently, often referred to as “dual diagnosis” care. Most non 12 Step based programs also tend to be out of network.
  3. You will likely be able to be reimbursed for more extensive care with an out of network provider. Many insurance providers will only reimburse for a couple of weeks of residential addiction treatment at an in network facility, even though research indicates that a minimum of 30 days is much more likely to be effective in treating substance use disorders. The same plans often reimburse for much longer stays at an out of network facility, such as up to 90 days for residential or day treatment care.