Ambetter Health Insurance Coverage for Addiction Treatment

Ambetter is a health insurance company that started offering ACA compliant insurance plans in 2014. They’re owned by Centene Corporation. Their geographical span is nearly nationwide with plans available in 29 states and they serve more than four million members.

The company primarily offers individual and family plans on the Insurance Marketplace of each state they operate in. They can also help employers set up an Individual Coverage Health Reimbursement Arrangement (ICHRA) to provide employees with health coverage.

Beyond regular health insurance plans Ambetter also offers dental and vision insurance in most states.

Does Ambetter Insurance Cover Addiction Treatment?

All of Ambetter’s health insurance plans are offered on the Insurance Marketplace so they all cover the 10 essential health benefits required by the Affordable Care Act (ACA). That list of essential benefits includes mental health and addiction treatment.

However, every plan is different in terms of how much coverage you have and what requirements you need to meet. For example you might need to get a referral or preauthorization before insurance coverage is approved.

The provider networks and level of coverage vary state by state but they make it easy for you to check their coverage for yourself even before you sign up. If you are considering an Ambetter plan you can get the details of the plan from the state Marketplace before you enroll. If you’re already a member you can review your insurance by visiting their website and logging into your account.

What Types of Plans Does Ambetter Carry?

You can get a plan from them that’s either an HMO or an EPO or a PPO. There are a few rare instances where you can get a POS plan. Here’s how each plan works.

If you have an Ambetter Health Maintenance Organization (HMO) plan you’ll need to name a primary care provider (PCP). This will be the main doctor you see and they will coordinate your care by providing referrals to specialists. An HMO also requires you to use in network providers unless you’re in a life threatening emergency.

In most cases an addictions counselor and psychiatrist count as specialists who you need referrals for and you may also need preauthorization before you start treatment. That’s why it’s important to work with your PCP to create a treatment plan before you choose a rehab.

In an exclusive provider organization (EPO), you’ll only be able to get services from providers that are part of your plan’s network. Any care you get from outside of their network won’t be covered. However you won’t need to coordinate care through a PCP or get referrals to see specialists. You might still need preauthorization for certain services though so be sure to double check before you start treatment.

Ambetter has Preferred Provider Organization (PPO) plans in some states. These types of plans are usually more expensive in terms of monthly premium because they give you more freedom to choose who you want to see. They still have a network that they encourage you to use but if you want to see someone outside the network they will usually cover at least part of the cost. If you go out of network you’ll have a higher out of pocket costs and deductible than if you use an in network provider.

A Point of Service (POS) is the plan type that Ambetter offers the least frequently and it’s not available in most states. If you happen to be considering one the important thing to know is that your primary care provider acts as your care coordinator.

For any specialty care you’re thinking of getting you will have to see your primary care and get a referral. This will likely include your counselor and psychiatrist. The way this plan differs from an HMO is that you do have the freedom to get care from outside the plan’s provider network. You will likely have a higher deductible and higher copayments and coinsurance if you do.

What Perks Are Available With Ambetter Plans?

With Ambetter Perks you get deals on products and services that support your health and well being. You can get discounts on gym memberships and meal services as well as travel, entertainment and restaurant services. My Health Pays® also rewards you for keeping up with good health practices like getting a yearly physical exam and eating well.

Other perks like DispatchHealth and health management programs along with the 24/7 nurse advice line and Walgreens SmartSavings make healthcare and prescriptions more affordable and accessible with your membership.

What Inpatient Addiction Treatment Does Ambetter Cover?

Ambetter offers coverage for medically necessary care. That’s why before you choose a rehab facility you should devise a treatment plan with your doctor. This way you can get the referrals and documentation you may need to get coverage for inpatient addiction treatment.

Before you receive treatment getting the ASAM Criteria Level of Care Assessment from your doctor will help determine your specific needs and whether or not they recommend inpatient care. You may also need to meet certain criteria for residential care like a diagnosis of chemical dependency and medical stability after detox.

Medical detox gives you supervision from medical professionals who can provide care to help you manage your withdrawal symptoms. That sometimes includes medication assisted treatment (MAT) as well as other types of care.

When you enter residential care be prepared to continue with your program for 30 to 90 days depending on your treatment plan and care needs. During this time you’ll receive structured care including group and individual therapies and do various therapeutic activities. Having access to medical detox and inpatient treatment can offer additional support that increases the likelihood of long term recovery.

What Outpatient Rehab Does Ambetter Cover?

Ambetter covers various forms of outpatient treatment depending on your plan and what is medically necessary for your treatment. It may cover partial hospitalization programs (PHP) and intensive outpatient programs (IOP) as well as general outpatient treatment.

PHPs and IOPs both offer more structured treatment than general outpatient treatment. With a PHP you typically get at least 20 hours of intensive treatment each week including group and individual and even family therapy as well as holistic treatments. An IOP usually involves 9 to 15 hours of weekly therapy spread over several days and it has more flexibility than a PHP.

General outpatient treatment lets you go about your daily life and work your treatment around it. You may do treatment sessions in the evenings or on weekends, and the intensity of that treatment varies based on your needs. It can also be included as part of aftercare from a residential, PHP, or IOP program. Aftercare can act as continued support through recovery meetings and peer support along with counseling.

Does Ambetter Cover Methadone & Suboxone (MAT)?

Ambetter may cover MAT if it is a necessary part of your substance use treatment plan. You may need MAT as part of medical detox or for continued treatment for opioid and alcohol use though the extent to which you receive it depends on individual factors.

Much of the time you’ll receive methadone or suboxone to help reduce withdrawal symptoms as you detox or to help you stay medically stable over a longer period of time so you can pursue treatment with a lower risk of relapse.

Both medications are synthetic long acting opioids that block the euphoric effects of opioids like heroin or oxycodone. Suboxone combines buprenorphine and naloxone and is sometimes used as a less addictive option than methadone. However with professional supervision both are safe treatments for addiction.

Does Ambetter Cover Other Mental Healthcare?

Ambetter only offers ACA compliant insurance so your plan does cover other mental healthcare. It covers care options like psychotherapy and psychiatry through group and family therapy. You may also be able to get inpatient treatment and crisis support for many mental health disorders. That can include anxiety and depression as well as bipolar disorder and OCD and many more.

Because substance use disorders often co occur with other mental health disorders it’s important to treat them too. By understanding and treating these co-occurring disorders simultaneously you can increase your success with long-term recovery by giving you more tools and support so you have the right care for all your needs.