Blue Cross Blue Shield insurance coverage encompasses 36 separate companies and 105 million insured in the U.S., resulting in one in three Americans having some sort of coverage through the company. This means that millions of people count on Blue Cross Blue Shield drug rehabilitation coverage every year, including about half of all federal employees. Anyone insured under the BCBS banner must understand coverage of Blue Cross Blue Shield drug rehab facilities.
Learn About BCBS Drug Rehab Insurance Coverage:
Does Blue Cross Blue Shield Cover Drug Rehab?
In general, Blue Cross Blue Shield insurance does cover drug addiction rehab. However, the specifics of this coverage will vary depending on which company under the BCBS banner a person has coverage with. Most policies will cover the following types of drug rehab:
- Outpatient treatment
- Residential treatment/detox
- Partial hospitalization
- Acute inpatient hospitalization
If someone depends on Blue Cross Blue Shield health insurance for drug rehab, they should check with their company to determine what types of rehab it will cover.
Does Blue Cross Blue Shield Cover Inpatient Drug Rehab?
The simple answer is yes, Blue Cross Blue Shield rehab coverage includes inpatient drug rehab. The more nuanced answer is that Blue Cross Blue Shield insurance coverage extends to inpatient rehab for the majority of people they insure, but there are restrictions in most cases.
For example, a large percentage of those insured by BCBS have an HMO. These individuals can only expect their inpatient drug rehab to be covered if they select one that has contracted with their HMO.
Assuming that someone has a policy that covers drug rehab, and they select an in-network provider, BCBS should be able to help with the cost of treatment. However, that does not mean they will pay for it in full. Whether someone has Blue Cross Blue Shield COBRA or individual insurance or another product, they should expect to pay some of the cost out of pocket. Just some of the costs that will be on those insured through federal programs are as follows:
- If someone has the standard option, $350 in copay.
- If someone has the basic option, anything past $875 per admission.
- If someone has FEP Blue Focus, anything after 30% of their allowance.
In other words, while having BCBS coverage can make rehab more affordable, it does not mean it will be free to anyone with their insurance coverage.
Does BCBS Cover Outpatient Drug Rehab?
Just like with inpatient coverage, Blue Cross Blue Shield drug rehab policies will cover outpatient rehab in most cases. There are limits, and a big one is that users will generally need to opt for an in-network provider. If someone has BCBS coverage for outpatient rehab and selects an in-network provider, they should expect to pay for part of their treatment.
Some of the costs that those insured through federal programs will need to cover are:
- If someone has the standard option, anything after 15% of their allowance.
- If someone has the basic option, anything past $100 per day.
- If someone has FEP Blue Focus, anything after 30% of their allowance.
While this does mean that the individual will be paying for part of their rehab, having this coverage makes it more affordable at approved Blue Cross Blue Shield drug rehab facilities.
BCBS Substance Abuse Coverage Policy
Researching Blue Cross Blue Shield insurance for rehab is tricky because there are so many variables at play. Each of their 36 companies uses slightly different language in their policies, and each company’s policies are divided into multiple tiers. In most cases, these are as follows:
What each of these tiers cover will depend on the state the policy was issued in, the level of care being sought, and even the financial status of the insured in some cases. Below is a glance at what might be covered for each tier with inpatient and outpatient drug rehab.
|Plan||Inpatient Rehab||Outpatient Rehab|
|Bronze||The insured must meet the deductible for in-network providers. Out-of-network providers are not covered.||The insured must meet the deductible for in-network providers. Out-of-network providers are not covered.|
|Silver||A coinsurance percentage is charged in addition to the plan’s deductible for in-network services. Out-of-network is not covered.||A coinsurance percentage is charged in addition to the plan’s deductible for in-network services. Out-of-network is not covered.|
|Gold||After reaching the deductible, coinsurance percentage is required, but this is usually smaller than that of the silver tier. Out-of-network services are not covered.||After reaching the deductible, coinsurance percentage is required. Out-of-network services are not covered.|
|Platinum||In-network has a copay per day or a coinsurance percentage the insured must pay. Out-of-network providers may be covered with a higher deductible or coinsurance percentage.||Varying copays or coinsurance percentages are charged for anything in-network. Out-of-network providers may be covered with a higher deductible or coinsurance percentage.|
To find out the specifics of their plan, insured individuals should contact their provider.
Federal Employee Program Plans
Federal employee programs have different tiers than the standard packages offered by the company. These tiers are: Standard, Basic, and Blue Focus. Each of these plans will grant different levels of coverage.
|Criteria||Standard option||Basic option||FEP Blue Focus|
|Preferred Drug Coverage||Yes||Yes||Yes|
|Non-preferred Drug Coverage||Yes||Yes||No|
|Access to Mail Service Pharmacy||Yes||No||No|
|Medicare Part B Reimbursement – $600||No||Yes||No|
Self + One and Self & Family
Self + One and Self & Family
Depending on the type of care an individual needs, all of these aspects of substance abuse coverage could be important regarding Blue Cross Blue Shield drug rehab coverage.
How To Know If A BCBS Policy Covers Drug Rehab
Anyone who needs drug rehab and has Blue Cross Blue Shield insurance should verify the coverage they have. To do this, they need to determine who their specific carrier is and what is their policy ID number. With this information, they should be able to call the company and determine what their benefits are and how to use them. The company will also be able to assist them in finding a suitable drug rehab facility.
Anti-Addiction Drugs Covered By BCBS Insurance
Drug rehab often requires the use of medications to help people detox and stay clean. Blue Cross Blue Shield rehab coverage does extend to medications. However, whether or not a specific medication is covered can vary.
Commonly Covered Medications
Pharmaceutical use is covered under Blue Cross Blue Shield drug rehab policies. However, they are allowed to limit the medications they cover and refuse coverage under certain circumstances. The rehab drugs they most commonly cover are Suboxone, Zubsolv, and Buprenorphine/Naloxone. However, for BCBS to cover them, the insured must meet the following criteria:
- They are actively being treated for addiction to opioids
- Their prescribing physician has the correct training and all appropriate DEA waivers
- They have signed an informed consent document
- They are at least being offered behavioral health treatment and psychosocial support
- Their prescribing physician has certified a preferred pharmacy chain
If these criteria are met, Blue Cross Blue Shield insurance policies will cover drug rehab with these medications.
Methadone Treatment Coverage
Treatment with methadone is covered by Blue Cross Blue Shield health insurance through the process of reimbursement. It is coded as H0020: Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program). In addition to providing coverage of the medication itself, it also covers the following:
- Associated physician services
- Associated nursing services
- Cost of administration, including automated equipment
- Toxicology of lab fees
- Patient care monitors
- Security costs
- Patient education
- Primary care provider referrals
- Emergency services
- Crisis management
- Special services for pregnant women
- TB risk assessment
- Associated transcription and data entry
- Coordination of care
Although Blue Cross Blue Shield insurance plans for substance abuse cover methadone, the need for it must be well documented for the company to extend coverage.
Drug Testing Policy During Treatment
For many individuals, being drug tested on a regular basis is part of the rehab process, as well as maintenance after active rehabilitation has ceased. The process of getting this covered begins by adding the insured’s drug of use to their profile. Once those are added, it sets the scope for testing, as it will be limited to those drugs or any substances that have been identified as drugs of use in subsequent evaluations.
Blue Cross Blue Shield insurance does cover testing. Drug testing coverage is limited to 20 tests per the calendar year unless the insured seeks special approval.
Items that are covered include the following:
- Presumptive and definitive (qualitative or quantitative) drug testing methods after a drug has been detected through a screening or presumptive test if a provider has submitted a written request
- A single multi-drug screening per day
- Restrictions are waived during emergency room visits, ambulatory surgery, and after inpatient admission
Drug testing that BCBS does not cover includes:
- Tests ordered by third parties, such as courts or employers
- Tests ordered by medical doctors without Clinical Laboratory Improvement Amendment (CLIA)
- Certification appropriate to the specific services rendered
- Hair drug testing
- Oral fluid testing
- Tests ordered without a written request signed by hand stating the following:
- Substances to be screened for
- If adulteration testing is needed
- Is confirmatory testing is needed
- What the diagnosis is that necessitates the testing
Ultimately, users should have access to any testing they authentically need through Blue Cross Blue Shield rehab coverage.
Verify Coverage Through BCBS And Begin Treatment
If someone has Blue Cross Blue Shield insurance, substance abuse treatment is covered in most circumstances. Anyone with this coverage and a substance use disorder should verify their coverage. Once they do, they can find a facility within their network and begin their journey towards getting clean.
- BENEFIT SUMMARY BOOK: 2019 BLUE CROSS AND BLUE SHIELD SERVICE BENEFIT PLAN. Blue Cross Blue Shield . 2019. https://media.fepblue.org/-/media/PDFs/Brochures/2019_Benefits_SummaryBook.pdf.
- Behavioral Health & Substance Use Disorders. Blue Cross Blue Shield . 2019. https://provider.bluecrossma.com/ProviderHome/wcm/connect/1721ea4c-a3ff-4876-8c89-6aaf883c4a7d/BH_and_substance_abuse_payment_policy.pdf?MOD=AJPERES&CONVERT_TO=URL.
- Drug Testing: Payment Policy. Blue Cross Blue Shield . 2019. https://provider.bluecrossma.com/ProviderHome/wcm/connect/e29b2359-9158-4cd6-9bcf-67bec43517cf/urine_drug_testing_payment_policy.pdf?MOD=AJPERES&CONVERT_TO=URL.