Wellmark Inc. Insurance Coverage for Drug & Alcohol Rehab

Wellmark, Inc. is a mutual insurance company and an independent licensee of Blue Cross Blue Shield Association. A mutual insurance company is owned by its policyholders and not by investors. As an independent licensee, they have access to Blue Cross Blue Shield resources but can act independently to provide customized plans for their local community.

Wellmark offers insurance coverage to people throughout Iowa and South Dakota. They are accredited by the National Committee for Quality Assurance, and each year the company publishes how the premium dollars are spent to stay accountable to policyholders and reduce unnecessary costs.

Wellmark was founded in 1939 as Wellmark Hospital Service Incorporated of Iowa. This later became Blue Cross of Iowa. The name Wellmark was adopted in 1997, and then in 2016, they created two new companies so plans could be delivered on and off the Health Insurance Marketplace.

Does Wellmark Insurance Cover Drug Rehab?

Most health insurance policies written by Wellmark cover drug rehab and addiction treatment. However, there are exceptions to this rule. The 2010 Affordable Care Act mandates that most individual and small employer health plans offer essential health benefits, including mental health and substance use disorder treatment.

However, not all plans fall under this law, so it’s important to verify your insurance before committing to a treatment center. Getting the details of your insurance coverage will help ensure you are not surprised by unexpected bills when you’re trying to focus on your recovery.

What Are Wellmark Plans?

Wellmark offers several insurance plans to help cover Iowa and South Dakota residents.

The employer plans are available for all sizes of businesses. The plans and benefit packages available are based on employer size and the state where the plans are offered. Employers who need small group plans in Iowa can choose a range of coverage from strictly in state to national access for employees, while employers in South Dakota have access to more traditional healthcare offerings.

Wellmark also offers individual and family healthcare plans in each state’s Insurance Marketplace. Plans are in one of three tiers – Gold, Silver, and Bronze. The Gold tier plans are more expensive in terms of monthly premiums but cover around 80% of the cost of care. Bronze plans have lower premiums but only cover 60% of care. Silver plans are in the middle and cover 70% of care.

Wellmark also has Medicare Advantage and Medicare supplementplans for people in Iowa and South Dakota who qualify for Medicare. A Medicare supplement plan helps cover some of your out of pocket expenses in Original Medicare. A Medicare Advantage plan replaces Original Medicare but generally includes additional benefits. However, you will generally need to use the Advantage plan’s provider network and you may need preauthorization for care.

How to Verify Coverage With Wellmark

Given that every plan is different, it’s important to verify your insurance coverage and understand your limits so you are not surprised by unexpected bills during or after treatment.

There are two main ways of verifying your insurance and understanding your coverage level. The first is to contact Wellmark member services who can answer questions about your specific policy, let you know if prior authorization is required before treatment can begin, and tell you about your benefit limits.

The second way is to work with the treatment center of your choice. They often offer the service of contacting your insurance provider to verify your coverage. This includes information about prior authorization or limitations on the type of treatment or the number of times you can receive treatment in one year.

Many treatment centers also offer initial phone assessments to determine if you are a good candidate for their program, and can connect you with their financial counselors to help estimate your out of pocket expenses.

How Much Does Rehab Cost Without Insurance?

The cost of drug rehab without insurance can be significant. However, if you do not have insurance, you may qualify for state or federal funding to help cover the cost, including Medicaid or other special state funding programs.

Generally, the cost of rehab depends on several factors, including your customized treatment program, the geographical location of the treatment center, the length of your treatment program, and whether you require inpatient or outpatient care. The National Center for Drug Abuse Statistics tracks the average cost of drug rehabilitation over all states.

The average episodic cost for adult residential treatment was $9,800 and the average for an intensive outpatient program was $5,000. These costs vary depending on where you live.

What Inpatient Addiction Treatment Does Wellmark Cover?

Wellmark covers inpatient addiction and substance abuse treatment when it is deemed medically necessary by a physician. So, you may need to get a referral from your medical provider, with a treatment plan included, to be eligible for coverage of inpatient addiction treatment.

Your treatment may start with medical detox which may use medication assisted treatment (MAT). You’ll have medical support and perhaps FDA approved medications to help you get through the uncomfortable symptoms associated with detox.

Inpatient treatment takes place in a hospital or clinic, and residential care happens in a facility that offers a more home like environment. Inpatient and residential treatment provide around the clock support in a structured environment. Treatment is provided by credentialed clinical staff, including medical and mental health professionals. During residential and inpatient treatment you are away from everyday life so you can fully focus on your recovery.

What Outpatient Rehab Does Wellmark Cover?

Outpatient addiction treatment is generally part of Wellmark’s behavioral health and substance use disorder coverage. You’d need to check the details about your plan to see what requirements there are and what coverage you have. There are multiple types of outpatient treatment that may be part of your treatment plan.

The most intensive option is a partial hospitalization program (PHP) which provides 20 or more hours of addiction treatment each week, scheduled over 4 to 7 days. A PHP program often lasts 3 to 4 weeks. The next level is an intensive outpatient program (IOP) which usually provides 9 to 20 hours of treatment each week, with the program running for a total of 4 to 8 weeks.

Finally a regular outpatient program (OP) typically meets once or twice a week with sessions that last 1.5 to 4 hours each. The length of these programs varies by facility but it’s common for them to last 30 days.

Many outpatient treatment programs offer aftercare services once you finish treatment. These services might include additional counseling sessions, 12 step peer group recovery meetings, and alumni meetings that offer socialization opportunities.

Does Wellmark Cover Methadone & Suboxone (MAT)?

MAT (medication assisted treatment) can be used in detox and/or as an ongoing treatment for alcohol or opioid addiction. It’s recommended that MAT be used in conjunction with evidence based treatment to help you lay a solid foundation for recovery.

Methadone and Suboxone are FDA approved opioid treatment medications. Suboxone is a combination of buprenorphine and naloxone. If you are diagnosed with opioid use disorder (OUD), your primary care physician could refer you to a certified opioid treatment center. In that case, most Wellmark plans would provide coverage. But, since healthcare plans vary, you should always verify your coverage by contacting the insurance company.

MAT can also be used to treat moderate to severe alcohol use disorder (AUD). Naltrexone is used as a MAT medication for alcohol misuse. You would start with detox before starting MAT. Naltrexone blocks the euphoric effects of both opioids and alcohol and decreases cravings for both drugs.This can help you stay stable and avoid relapse while you work on your recovery.

Does Wellmark Cover Other Mental Healthcare?

Following the guidelines of the Affordable Care Act most Wellmark plans do offer mental health care. However services vary by plan and there are exceptions. So, always verify your specific coverage before you start treatment. Mental health treatment options available in Wellmark plans may include crisis care, counseling, psychotherapy, and medication management.

Dual diagnoses — where a person has a mental health disorder and an addiction as well — are common. In such cases, both conditions should be treated simultaneously using a coordinated treatment plan. If you have a dual diagnosis be sure to find a rehab center with the integrated services you need to assure long term success.

Can I Travel Out of State For Treatment With Wellmark?

In most cases, Wellmark members have plans that utilize a pre authorized network of local providers. So, most members will not be covered if they travel outside their network coverage area for services.

A few Wellmark plans include out of network coverage which means and they may pay for some services delivered by out of state providers. However the extra expenses incurred (through higher premiums and copays) makes this choice challenging for many people. If you choose to pursue out of network care be sure you’re aware of the higher costs.

You can often find many high quality addiction treatment center options within the provider network of your Wellmark plan. To maximize your insurance coverage it’s a good idea to choose one of these if possible.