Will Insurance Cover an Addiction-Caused Hospital Trip?

Will Insurance Cover an Addiction-Caused Hospital Trip?

When it comes to substance abuse disorders and addiction-caused hospitalization, it is important that you have a clear picture of your insurance company’s offerings. To learn more about whether your insurance will cover an addiction-caused hospital trip, you might want to get a better understanding of the Mental Health Parity and Addiction Equity Act, learn about the Affordable Care Act, and get insights into how to work with your insurance carrier to get the services you need.

Mental Health Parity and Addiction Equity Act

The National Alliance on Mental Illness (NAMI) provides considerable information about the aspects of mental health parity and the services that are now required by law. In their post “What is Mental Health Parity?”[1] you learn about the basics of mental health parity and what your insurance companies are required to provide.

The Mental Health Parity and Addiction Equity Act implemented in 2008 requires employers to provide equal treatment of mental health conditions and substance use disorders in insurance plans as they would for other medical services. For example, if the plan provides unlimited doctor visits for a chronic condition like diabetes then they must offer unlimited visits for a mental health condition or a substance abuse disorder.

It is important to be clear that you understand that parity simply means equivalent, so you need to review your health insurance policy carefully to determine what you can expect. If your current health insurance plan is very limited, then mental health coverage will be similarly limited.

You also want to check if your plan is required to meet federal parity requirements. If so, then it must equally cover treatment and payment amounts for services including the following:

  • Inpatient in-network and out-of-network
  • Outpatient in-network and out-of-network
  • Intensive outpatient services
  • Partial hospitalization
  • Residential treatment
  • Emergency care
  • Prescription drugs
  • Co-pays
  • Deductibles
  • Maximum out-of-pocket limits
  • Geographic location
  • Facility type
  • Provider reimbursement rates
  • Clinical criteria used to approve or deny care

Don’t assume that these services are automatically covered. You will want to check with your insurance provider who might have criteria for medical necessity, meaning the treatment or supplies are considered by the health plan to be reasonable, necessary, and/or appropriate.

The Affordable Care Act

Dr. A. Thomas McLellan, the former Deputy Director of the White House Office of National Drug Control Policy talks about the Affordable Care Act in the DrugFree.org post “Affordable Care Act to Provide Substance Abuse Treatment to Millions of New Patients.”[2]

At the time of the post in 2013, Dr. McLellan reported that 23 million American adults suffer from substance abuse or dependence, which he pointed out, is about the same number of adults who have diabetes. Of even greater concern according to his report is that an additional 60 million people engage in “medically harmful” substance use, which is the use of drugs or alcohol that could eventually lead to a medical condition such as liver disease or cancer.

Under the requirements in the Affordable Care Act, substance abuse treatment is part of primary care and is focused more on prevention. Health plans are required to treat the full spectrum of the disorder, including people who are in the early stages of substance abuse. This requirement is designed to encourage prevention and early intervention, as well as quality treatment options.

The Affordable Care Act requires government insurers to cover services including the following:

  • Physician visits
  • Clinic visits
  • Home health visits
  • Family counseling
  • Alcohol and drug testing
  • Some medications designed for substance abuse.

The Act extends beyond inpatient services and detox program to cover services with a goal to offer primary care prevention and management services.

Getting the Services You Need

In addition to federal parity requirements, 43 states and the District of Columbia have state parity requirements for commercial group health insurance plans. These requirements include managed care to provide coverage for addiction treatment. If you live in Arizona, Georgia, Idaho, Indiana, Iowa, Oklahoma, or Wyoming, you do not have state parity requirements. The HBO.com post, “Can’t Get Treatment Through Your Health Insurance Plan?” gives insights on how you can ensure that you are getting coverage for the services that you need.[3]

The first thing you want to do is check your coverage for addiction treatment in your employee benefit handbook. If you have any questions about it, ask the employer’s administrator to answer any of them for you. In some cases, an employer can override the decision of the health plan or managed care firm. Next, contact the insurer directly to clarify your benefits. It is important that you document all interactions with the health plan and keep copies of all materials and correspondence.

You would then contact addiction treatment facilities and local hospitals to determine if addiction treatment services, including addiction-caused hospital trips would be covered by your insurance. It is important for you to do your homework as much as possible because you may want to voice your concerns to either local or state legislators, the state insurance department, or the state health department.

Throughout this process, you may need to explore alternative funding for services. At each step along the way of doing your homework, ask each resource if they know of any other funding options. You don’t want lack of health coverage or funding to prevent you from getting the treatment you need.

Get Help to Learn More About Insurance Coverage for Addiction-Caused Hospital Trips

If you or a loved one is struggling with an addiction to Rohypnol or other substance, please call our toll-free helpline today. Our admissions coordinators are available 24 hours a day to answer your questions and provide you with useful resources.


[1] NAMI. “What is Mental Health Parity.” https://www.nami.org/Find-Support/Living-with-a-Mental-Health-Condition/Understanding-Health-Insurance/What-is-Mental-Health-Parity

[2] DrugFree.org. http://www.drugfree.org/join-together/affordable-care-act-to-provide-substance-abuse-treatment-to-millions-of-new-patients/

[3] HBO.com. http://www.hbo.com/addiction/treatment/362_not_covered_by_insurance.html