Will EmblemHealth Help Cover Drug Rehab and Treatment?

Medically Reviewed

The Affordable Care Act (ACA) dictates that mental health, behavioral health treatment, and substance abuse treatment services fall into one of the 10 “essential health benefits” that must be treated with parity, or equally, to other medical and surgical procedures.

This means that at least some level of drug rehab or drug abuse treatment services is covered through EmblemHealth insurance plans.

Company Overview

Health Insurance Plan of Greater New York (HIP) and Group Health Incorporated (GHI) merged to form EmblemHealth, which serves more than three million people in the Tristate and New York City area. It is one of the biggest not-for-profit health insurance providers.

EmblemHealth offers both government-sponsored and commercial health care plans to individuals, families, and employers. There are many types and levels of EmblemHealth coverage with federal- and state-sponsored Medicaid and Medicare health plans, as well as private health insurance options.

Coverage for Drug Rehab Through EmblemHealth

If you’d like to use EmblemHealth insurance to pay for drug rehab services, the Emblem Behavioral Health Services program can provide details on your specific plan, provider options, and what to do if you think you or a loved one may need professional help. This program can help you to determine if you qualify for additional services and support through EmblemHealth.

An EmblemHealth representative can also talk you through your coverage, letting you know what your plan covers and how to use it.

Medicaid beneficiaries covered through Health and Recovery Plans (HARP), under Health Home, can set up a managed care system that will coordinate both behavioral health and physical health treatment services in tandem.

EmblemHealth has an extensive network of providers. You can often get coverage with these providers without a referral for services. Log into your EmblemHealthaccount, and use the “Find a Doctor” tool to locate a behavioral health and substance abuse treatment provider.

If you are using an outside provider, and your insurance coverage allows it, you may need prior authorization or a referral from your primary care provider (PCP) to be covered. Out-of-network providers are generally covered at a lower rate and cost you more out of pocket than using an in-network provider.

Substance abuse and addiction treatment services, such as drug rehab, usually need to be classified as “medically necessary” by your PCP before they are covered. At that point, services like detox, counseling and therapy, outpatient programs, medication management, and inpatient drug rehab may be included to some extent.

Each plan will be different and offer variable levels of coverage. A representative from EmblemHealth can help you understand your coverage better.

Levels of Coverage with EmblemHealth

EmblemHealth offers many different types of plans and levels of coverage that feature drug abuse and addiction treatment services through GHI, HIP, Medicare, Medicaid, and Child Health Plus, InBalance, ConsumerDirect, CompreHealth, Vytra, Montefiore, and EmblemHealth directly.

Plans with substance abuse treatment coverage through EmblemHealth include:

  • HMO plans. A health maintenance organization (HMO) plan provides a high level of coverage for services within the network. When seeing a provider through this vast network, coverage is provided at the set co-insurance rate. Whatever the percentage of the co-insurance, that is the percentage of the total for services that you will be responsible for paying after your deductible is met, up until your annual out-of-pocket maximum is reached.
  • EPO plans. Exclusive provider organization (EPO) plans require members to remain in-network for all services for coverage to be provided. These plans often have higher deductibles that will need to be met prior to co-insurance rates kicking in for coverage.
  • POS plans. With a point of service (POS) plan, you can typically receive care and obtain services from your chosen provider regardless of whether or not they are within your network. You will pay more for out-of-network care.
  • PPO plans. A preferred provider plan (PPO) allows you to receive care from an out-of-network provider for a higher cost than you would be charged at an in-network provider.
  • Medicare, Medicaid, and Medicare Advantage. These plans are sold on the federal marketplace, and they are funded by the state and federal government. For New York residents, these EmblemHealth plans are low cost or free to eligible residents. Beneficiaries will need to be children, disabled, elderly, families with children, or demonstrate financial hardship.

Rehab Coverage

Often, there are specifications on coverage for drug rehab when it comes to health insurance. Due to the ACA, plans that are offered on the federal marketplace must provide the same level of coverage for drug and alcohol abuse and addiction treatment services as they do for other medical and surgical conditions and procedures. This means that care management, treatment, and financial considerations must be equal; therefore, health insurance coverage can usually be used for drug rehab.

EmblemHealth is not a profit-based company. This allows them to take a more personal and community-based approach to health care and health insurance coverage.

Drug rehab providers, as well as the health insurance provider, can help you navigate your health plan and coverage options.

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