Rehab Centers that Accept BlueCross BlueShield Insurance

Insurance coverage typically depends on the type of plan you have, the rehab center’s network status and your location. BlueCross BlueShield also considers medical necessity, prior authorization requirements and benefit design when making rehab coverage decisions. Rehab centers may be in-network or out-of-network, so check your plan documents to determine what type of coverage is available.

This guide provides an overview of BlueCross BlueShield rehab coverage, including how BCBS benefits typically apply to addiction treatment. You’ll also learn how to verify your benefits.

BlueCross BlueShield often covers drug and alcohol rehab, but it depends on the terms of your plan. One of the biggest determining factors is whether the rehab facility is in-network or out-of-network.

Out-of-network coverage options are available and allow you to get care even if in-network options don’t meet your needs. However, you may have to pay a higher percentage of the approved cost.

Coverage also depends on what type of plan you have. Preferred provider organizations (PPOs) and exclusive provider organizations (EPOs) may offer more coverage than health maintenance organizations (HMOs). Point-of-service (POS) health insurance combines features of HMOs and PPOs, so you may be able to get out-of-network care with a POS plan.

BlueCross BlueShield rehab coverage also depends on prior authorization, medical necessity and your plan’s cost-sharing requirements. For example, it’s important to check the status of your deductible and out-of-pocket maximum.

BlueCross BlueShield typically offers different levels of coverage for inpatient and outpatient behavioral health services. Inpatient care is more expensive, so you may have to pay a deductible and/or coinsurance. Outpatient care may be subject to a co-pay for each service.

Your BlueCross BlueShield plan may cover these categories of care:

• Medical detox
• Inpatient/residential
• Therapy
• Medication-assisted treatment (MAT)
• Aftercare

Under mental health parity laws, U.S. insurers must treat mental health services the same as medical services. As a result, some BlueCross BlueShield plans include substance use disorder treatment as a standard benefit. Coverage varies by plan type and network.

Understanding your BlueCross BlueShield coverage makes it easier to access care quickly. Your plan may cover the types of care described below.

BlueCross BlueShield may cover medical detox, but you typically have to meet specific criteria for this level of care. For example, you may have to demonstrate that you have a risk of severe withdrawal symptoms.

BlueCross BlueShield may also require pre-authorization or a length-of-stay review. Length-of-stay reviews help determine whether an insurer will continue covering detox services after the initial approval expires.

Inpatient rehab programs provide 24/7 structured care, so insurers place residential care in a higher cost category than other rehab services. BlueCross BlueShield is likely to require pre-authorization, and there may also be a length-of-stay review to determine if your plan will cover additional days.

Medication-assisted treatment combines FDA-approved medications with counseling and other therapies to help people with opioid use disorder. Opioids are powerful painkillers that change the way your brain perceives pain.

BlueCross BlueShield may split MAT coverage between medical and pharmacy benefits. Medical benefits typically apply to counseling and other therapies, while pharmacy benefits cover the cost of your medications.

BlueCross BlueShield may require prior authorization for MAT. Coverage also depends on your plan’s formulary, which is a list of covered medications organized into cost tiers.

BlueCross BlueShield may cover individual therapy, group therapy and other evidence-based approaches. However, your plan might not cover experimental or alternative therapies.

Dual diagnosis refers to a person having a substance use disorder and at least one mental health disorder at the same time. Some rehabs don’t provide standalone mental health treatment, so they only provide dual diagnosis support to individuals with co-occurring mental health conditions.

Common co-occurring disorders include depression and anxiety. If you have BlueCross Blue Shield, dual diagnosis support may be billed under your behavioral health coverage. Services may also be reviewed for medical necessity.

Coverage for step-down care varies. BlueCross BlueShield may cover aftercare under your behavioral health or outpatient benefits.

Depending on your plan, covered services may include:

• Individual therapy
• Group counseling
• Medication-assisted treatment
• Psychiatrist visits

You may need to obtain prior authorization or meet medical necessity criteria for continuing care. BlueCross BlueShield typically doesn’t cover recovery coaching, sober living or other nonclinical services.

A provider is in-network if they’ve agreed to accept your insurer’s discounted rates. Choosing an in-network rehab can lower your out-of-pocket costs.

If you use an out-of-network provider, you may have to pay a separate deductible or a higher coinsurance percentage. Depending on your state’s rules, BlueCross BlueShield out-of-network rehab coverage may even lead to balance billing, which is when a provider bills you the difference between the amount charged and an insurer’s “allowed” amount.

During treatment, you may receive care from outside providers. To provide an accurate estimate of your costs, verification should specify who will bill for each service.

If you have BlueCross BlueShield rehab coverage, the cost of care depends on several factors:

• Admission timing
• Benefit periods
• Level of care
• Length of stay
• Pharmacy costs for MAT (if applicable)

Out-of-pocket costs also vary based on your plan’s deductible, coinsurance and co-pays. A deductible is the amount you have to pay before BlueCross BlueShield starts covering addiction treatment services. Coinsurance is a percentage of the cost of a covered service, while a co-pay is a flat fee.

BlueCross BlueShield offers several plan types:

• HMO. An HMO limits coverage to in-network providers and facilities. You must also obtain a referral if you need specialty care.
• PPO. PPOs don’t require referrals. They also cover out-of-network care.
• EPO. EPOs limit coverage to providers and facilities within their networks. However, they don’t require referrals.
• POS. POS plans require referrals for specialty care. They cover out-of-network services, but usually at a significantly higher cost than in-network services.

In addition to its employer-sponsored plans, BlueCross BlueShield offers managed Medicaid, Marketplace and Medicare Advantage coverage.

You can find your plan type in these places:

• Insurance card
• Member portal
• Summary of Benefits and Coverage (SBC) document

DIY Verification Steps (Member)

1. Call the phone number on the back of your insurance card.
2. Ask if the rehab center is in-network or out-of-network.
3. Determine the authorization requirements for your level of care.
4. Ask about your deductible, coinsurance, co-pays and out-of-pocket maximum.
5. Find out if there are any limitations, such as visits, days or medical necessity reviews.

Fastest Option: Let a Rehab Verify for You

Generally, all you have to do is provide the name of your insurance company and your ID number. The rehab should be able to verify your benefits, including what’s covered and whether the facility is in-network or out-of-network. Verification is for information purposes only, as BlueCross BlueShield makes the final coverage determination.

If coverage is limited or denied, ask about:

• The reason for the denial
• How to begin the appeals process
• A required documentation list

You may also want to consider a clinical or peer-to-peer review. These processes may convince BlueCross BlueShield to reverse its original denial.

If the rehab is out-of-network, ask whether a single-case agreement is possible. This is when an insurance company treats out-of-network services as if you’re receiving them from an in-network provider. Single-case agreements are made at the insurer’s discretion.

Asking for help is the first step in recovering from a substance use disorder. Help.org can walk you through your benefits and help you find a rehab facility that fits your needs.

Call us or fill out the form below to explore your options. You’ll need your date of birth, member ID, group number and plan type.