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Anthem Blue Cross Rehab Coverage: Does It Cover Substance Abuse?

Last Updated: February 16, 2022

Authored by Nena Messina, Ph.D.

Reviewed by Michael Espelin APRN

Anthem insurance is one of the largest providers in the United States and is the biggest for-profit health care company under the Blue Cross Blue Shield banner. Approximately 40 million Americans rely on their rehab insurance cover should they require it. So what is anthem insurance? And how does it work?

What Is Anthem Insurance?

Anthem Insurance is one of the largest non-profit healthcare providers in the United States and has been functional since the 1940s. They are a giant collection of over 30 companies that come together to provide adequate healthcare in the US. 33% of all US citizens have a plan affiliated with them. Anthem is one of the companies part of the Blue Cross. Making it one of the most widely available plans in all 50 states.

Does Anthem Cover Drug Rehab?

Since Anthem is more widely known as being a “health insurance” provider, it’s not usually thought of as a company that might also specialize in rehab insurance for alcohol and other substance abuse disorders. They provide everything from crisis insurance, behavioral health, life, vision, disability, and dental insurance. With all of that, they’re also experts in offering drug and alcohol rehab programs.

Doctor writing a prescription at his office.

So yes, their health insurance plans do cover drug and alcohol rehab and other services related to substance abuse and mental health disorders. Insured individuals can use the rehab insurance at a wide variety of rehabilitation centers.

If the patient selects an out-of-network center or facility, they should understand that they will pay more than if they chose an in-network one. It can make the cost of rehab more challenging to afford and could result in the patient reaching their substance abuse coverage limits sooner.

Types Of Rehab Covered By Anthem

According to federal law, behavioral healthcare treatments must be extended to the same level of coverage as any other type of healthcare. It means that comprehensive overall cover would be the standard that Anthem meets. Anthem blue cross drug rehab coverage makes all types of rehab easy to access.

It Includes Rehabilitation Services Such As:

As such, patients can get the care that would help meet their needs best. However, they should speak with a healthcare provider in depth before settling on a specific rehab setup, as it could end up the best treatment isn’t the one the patient believes is best.

Anthem blue cross drug rehab coverage usually has two cover plans whenever a patient goes to a medical center or facility. In-network coverage and Anthem out-of-network coverage.

In-Network

In-network coverage is when the patient is seeking medical care from a healthcare facility, doctor, pharmacy, or lab part of the health plan contract that they use. That means that the particular center or facility would be contractually obligated to help provide the care to them. It’s their responsibility to provide the best care they possibly can, to the patient, at the lowest rates possible. Not only that, but they’re also going to help the patient file their claims and even request any of the pre-approvals they might need.

Anthem Out-Of-Network Coverage

Anthem out-of-network coverage means the opposite of the former plan. That is when the patient is at a healthcare facility, pharmacy, lab, or doctor that isn’t part of their health plan. Although they would still provide the necessary care for the patient, they may bill them for any amount they want. The charges are usually much higher than those that a patient would pay at an in-network center or facility, and while Anthem would still pay an allowed amount for the bill, the rest would be paid by the patient. A bill like this can also be called “balance billing.”

Covered Services For Anthem Blue Cross Substance Abuse Treatment

While this insurance does extend to substance abuse rehabilitation, it does not mean that anyone can just decide they need rehab and go, expecting it to be covered, nor does it mean they will automatically have access to all forms of rehabilitation options.

Female doctor in a hospital.

Being part of Blue Cross Blue Shield, Anthem blue cross substance abuse treatment coverage still has differences. When determining what they will and will not cover, Anthem bases its decision on something called “medical necessity.” If something is needed based on a strictly medical point of view, and the need for this medical treatment has been affirmed, Anthem blue cross substance abuse treatment coverage kicks in. If it is outside the preview of medical necessity, it isn’t covered.

Because what is medically necessary varies from person to person, it is impossible to list all services covered by Anthem blue cross substance abuse treatment. However, there are expenses associated with rehab that are not covered in the vast majority of cases.

These Include:

  • Spa services
  • Private rooms
  • Alternative therapies, such as acupuncture
  • Alternative treatments, such as music therapy
  • Executive facilities
  • Housekeeping
  • Food prep
  • Laundry services
  • Yoga

As a result, anyone who uses Anthem Blue Cross rehab coverage for a residential or inpatient facility will likely incur additional expenses they need to cover on their own.

Anthem Plan Levels

The plan a person has access to will determine their Anthem substance abuse coverage. The company divides its insurance plan into four tiers: bronze, silver, gold, and platinum. As long as the patient knows what tier of plan they have, they will be able to determine their out-of-pocket cost and what services are covered. Below is a chart covering essential substance abuse medical benefits and their prices through the Anthem Blue Cross rehab coverage tier (in-network and out-of-network costs provided are coinsurance after the deductible is met).

PLAN MEDICAL BENEFITS IN-NETWORK COST NON-NETWORK COST
BRONZE Outpatient treatment

Inpatient stay

35% 50%
SILVER Outpatient treatment

Inpatient stay

20% 50%
GOLD Outpatient treatment

Inpatient stay

20% 50%
PLATINUM Outpatient treatment

Inpatient stay

10% 50%

Ultimately, although their alcohol rehab coverage never covers the cost in full, having any of their policy tiers will make paying for rehab more accessible.

Prescription Drug Coverage

One of the best things about them is that they offer several plans for prescription drug coverage for most drugs. The people enrolled in the “Medicare Advantage Plan” will have prescription drug coverage included in their plan, with copays under $5. However, people who don’t have prescription drug coverage in their plan can also get a “Medicare Part D Plan” designed explicitly for prescription drugs.

Apart from regular prescription drugs, Anthem Blue Cross rehab coverage also covers Suboxone, a medication used widely across the US to help patients recover from drug addiction. Without any coverage, a month’s supply of Suboxone can easily cost up to $200, making it very hard for patients going through rehab to get enough of it for their entire addiction recovery journey.

Admission Criteria For Rehab Hospitalization

For an insured individual to have their Anthem Blue Cross rehab coverage, they have to meet the admission criteria established by the company. Even if a primary care physician has written a referral, the insurance coverage will not be extended if the patient fails to meet the requirements.

They Look at Three Criteria When Determining if They Will Approve Coverage:

  • Severity of illness
  • Intensity of service
  • Continued stay criteria

While precisely what these include will vary between types of rehab options, there are some similarities. Still, before entering a rehab center or facility, all patients should contact the company for clarification.

Severity Of Illness

To qualify for coverage, the patient must meet the DSM criteria for the condition they are looking to have treated. For example, to be eligible for addiction withdrawal recovery coverage, the patient must meet the criteria for a DSM Axis I or ICD-9 Substance Dependence diagnosis.

Intensity Of Service

It assesses whether or not the service the person is seeking coverage for meets the level of care that they need to make a full recovery. For example, if coverage for acute inpatient rehabilitation is requested, the facility must offer 24-hour care at the center. They should also have the patient seen by a physician at least once per day and have a plan for discharge from the day the patient is admitted to the point that they have made a full recovery.

Continued Stay Criteria

Continued stay criteria determine if the person needs to continue addiction treatment or can stop the treatment without significant risk. In most cases, this only asks that progress is being made and the insured person is not yet stable enough for the addiction treatment to stop or step down.

Verify Anthem Rehab Insurance And Start Treatment

Anyone battling a substance abuse disorder who has insurance coverage for drug rehab should have hope. They can access addiction rehabilitation treatment from numerous providers nationwide at extremely low costs through this coverage. However, each insurance plan is different, so every person needs to contact the company and discuss their options. It will make sure that the program they end up with will work best for them in the long run.

Frequently Asked Questions

What Does Anthem Cover?

There are several plans that one can get with them. They have individual, and family plans covering everything from preventative care, catastrophic coverage, diabetic treatments, dental, vision, drug rehab treatments, prescription drugs, and some facilities even cover weight loss treatments. Although the coverage might differ from state to state, it’s best to check with the provider to ensure what is covered under every specific plan.

Does It Cover Therapy?

Yes, they count mental health as a part of every person’s overall physical health. Mental health therapy is included in their “behavioral therapy programs.” However, it is important to note that the cost of therapy will differ between plans.

Does Anthem Drug Test?

The company doesn’t conduct their drug tests, but they do offer reimbursements for drug tests for some particular plans.

How Much Is Anthem Insurance?

There are several different insurance plans that one can use, and the prices can vary depending on the particular plan and if it’s an individual or family plan. Generally, the plans for individuals are between $360- $487 per month.

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Page Sources

  1. Substance Abuse and Mental Health Services Administration. Laws and Regulations. https://www.samhsa.gov/about-us/who-we-are/laws-regulations
  2. Anthem Blue Cross of California. Bronze Plan. https://chsu.edu/wp-content/uploads/Anthem-Blue-Cross-Bronze-Plan-Summary.pdf
  3. Anthem Blue Cross and Blue Shield Healthcare Solutions. Reimbursement Policy. https://providers.anthem.com/docs/gpp/NV_CAID_RP_DrugScreenTesting.pdf?v=202012081805

Published on: October 2nd, 2019

Updated on: February 16th, 2022

About Author

Nena Messina, Ph.D.

Nena Messina is a specialist in drug-related domestic violence. She devoted her life to the study of the connection between crime, mental health, and substance abuse. Apart from her work as management at addiction center, Nena regularly takes part in the educational program as a lecturer.

Medically Reviewed by

Michael Espelin APRN

8 years of nursing experience in wide variety of behavioral and addition settings that include adult inpatient and outpatient mental health services with substance use disorders, and geriatric long-term care and hospice care.  He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture.