How Does Insurance Cover Inpatient Rehab?
While most any form of medical treatment care can be costly, inpatient rehab costs run especially high. Depending on the location and types of amenities offered, an inpatient rehab stay can run anywhere from $15,000 to $27,000 for a 28-day stay. Without some form of health insurance coverage, many people simply wouldn’t be able to access needed treatment help.
Fortunately, recent changes in health care laws have made mental health and substance abuse treatment services accessible to those who otherwise wouldn’t be able to afford them. These changes go a long way towards covering many of the costs associated with inpatient rehab treatment.
Inpatient Rehab Services
Inpatient rehab program durations range from 30 to 90 days depending on the severity of a person’s condition. These programs take place within residential facilities or hospital settings and require patients to reside at the facility for the length of the program.
According to the National Center for Biotechnology Information, inpatient rehab programs administer acute treatment care in the form of medical, mental health and addiction-based services. Types of services offered include:
- Assessment of treatment needs
- Medical care for chronic conditions
- Psychosocial treatment interventions
- Medication therapies
Inpatient rehab programs provide 24-hour care and monitoring with a range of healthcare providers on hand. This includes:
- Case managers
The intensity of services offered coupled with specialty staffing provisions accounts for the high costs associated with inpatient rehab care.
The Affordable Care Act
Prior to 2008, health benefits afforded for mental health and substance abuse treatment were covered under the Mental Health Parity and Addiction Equity Act or MHPAEA. The MHPAEA required qualified health plans to offer the same level of benefits for mental health/substance abuse treatment as those offered for medical and surgical care.
Under the MHPAEA, only plans that choose to offer coverage for mental health/substance abuse treatment were required to provide the same level of benefits. According to the U. S. Department of Health & Human Services, as of 2008, the Affordable Care Act reclassified mental health/substance abuse as “essential” health care benefits.
As a result, health plan providers can no longer omit these coverages from their plans. In effect, mental health and substance abuse treatment now exists on the same tier as medical and surgical care benefits, which in turn make these benefits accessible to people whose plans didn’t include these coverages.
Standard Coverage Allowances
The reclassification of mental health and substance abuse treatment as essential health care benefits not only requires insurers to offer these benefits, but also requires them to provide the same coverage allowances that medical and surgical treatment carries, also known as standard coverage allowances.
As inpatient rehab treatment falls well within the substance abuse treatment category, standard coverage allowances for this level of care include:
- Coverage for out-of-network healthcare provides
- Copay allowances
- Coinsurance provisions
- Out-of-pocket maximums
- Allowances for the duration or number of days covered for an inpatient stay
These standard coverage protections work to prevent insurance providers from exercising discriminatory practices when paying health insurance claims.
Medicaid & CHIP Coverage Allowances
While the Mental Health Parity and Addiction Equity Act provided for inpatient rehab coverage benefits for commercial market insurance plans, these provisions did not apply for Medicaid and Children’s Health Insurance Program (CHIP) healthcare recipients.
According to the Substance Abuse & Mental Health Services Administration, substance abuse treatment benefits for Medicaid and CHIP recipients were covered under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. This law reclassified substance abuse treatment as an essential healthcare benefit granting Medicaid and CHIP recipients access to the same substance abuse treatment benefit coverages as commercial marketplace customers.
Essential Health Benefit Coverages
As a form of substance abuse treatment, inpatient rehab exists as one of 10 essential health benefit coverages listed under the Affordable Care Act. Essential health benefit coverages come with a range of provisions, all of which correspond with those afforded to medical and surgical-based services.
Provisions which now apply for mental health and substance abuse treatment services include:
- Treatment for mental and behavioral health services
- Coverage for pre-existing conditions
- Coverage caps
Mental & Behavioral Health Services
Services covered under mental and behavioral health treatment entail any condition deemed medically necessary by a physician or authorized healthcare provider. As inpatient rehab programs offer a range of specialty services, benefit coverages for this level of treatment will likely cover a smaller percentage of costs than other lower intensity level programs.
According to the U. S. Centers for Medicaid & Medicare Services, inpatient rehab service coverages include:
- Detox services
- Behavioral-based therapies
- Medication treatments
- Case management services
Ultimately, actual coverage amounts vary depending on the type of insurance policy a person has.
Coverage for Pre-Existing Conditions
People in need of inpatient rehab treatment often struggle with severe and/or long-term addiction problems. It’s not uncommon for addicts to have had pre-existing mental health problems prior to using drugs. Not surprisingly, pre-existing mental health issues actually increases the likelihood a person will engage in substance abuse practices.
As with medical and surgical insurance coverages, benefits for inpatient rehab treatment include coverage for pre-existing mental health problems. The same goes for “pre-existing” substance abuse problems in terms of having a past history of substance abuse.
Any form of treatment considered an essential health benefit receives certain valuable protections, one of which has to do with coverage caps. Coverage caps place dollar amount limits on how much a policy will pay out towards a certain type of treatment. Any medically necessary treatment deemed an essential health benefits has no yearly or lifetime dollar limits, which means insurance benefits can be used to help cover inpatient rehab costs each time a person requires this level of treatment.
While insurance coverage options do exist for inpatient rehab treatment, most people can expect to pay out-of-pocket costs all the same. In some cases, these costs may run considerably high.
What’s important to keep in mind is the cost of rehab versus the costs that come with addiction. The cost of addiction reaches well past the pocketbook, all but destroying a person’s quality of life, damaging relationships while impairing his or her ability to function in everyday life. In this respect, making the most of available insurance options in spite of the out-of-pocket costs will be well worth the expense.