The search for a drug and alcohol rehab program often starts with finding out what a person’s insurance plan will pay toward the cost of treatment. Avera Health Plans out of Sioux Falls, South Dakota, is a health insurance provider serving over 100 communities in the Midwest and offering coverage for addiction treatment.
Avera provides comprehensive health insurance to individuals, families, and employers and also offers a supplement to Medicare. What can people with an Avera Health Plans insurance policy expect the company to cover for drug and alcohol rehab?
Does Avera Cover Drug and Alcohol Detox?
As a proponent of integrated care, it is likely that Avera will cover drug and alcohol detox at one of many facilities. Avera collaborates with different centers throughout the coverage area and also operates the Avera Behavioral Health Center in Sioux Falls.
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A detox program provides emotional and medical support as a person stops using an addictive substance like heroin or alcohol and goes through withdrawal. Medical supervision is preferred during detox because withdrawal can come with potentially dangerous side effects such as:
- Muscle cramps
The extent of withdrawal symptoms will depend on the type of addiction and the severity of the addiction.
In some cases, withdrawal starts a few hours after last use and can last for many days. In some situations, withdrawal can last for a few weeks. During this time, medical staff monitors symptoms and provides various medications to make the process as comfortable as possible. After detox is completed, the patient will transition to a drug and alcohol rehab program where they’ll participate in therapy and develop relapse-prevention skills.
Most providers like Avera Health consider detox to be the start of the addiction treatment process, so they will usually pay for at least part of the detox services. How much they pay varies by policy and facility. Individuals should assume preauthorization is necessary before receiving care.
Does Avera Cover Inpatient Rehab?
Avera Health provides coverage for residential addiction treatment. The amount covered will depend on the type of policy the insured carries, whether individual, group or Medicare supplement, as well as the type of treatment program.
It is reasonable to assume Avera Health will require either a copayment or coinsurance fee. Copayments are amounts paid by the insured per day or per admission. If the plan states there is a copay of $250 per day for the first five days of inpatient treatment, the total out-of-pocket expense would be $1,250.
If the plan summary lists a flat copay amount without indicating a per-day requirement, it is safe to assume the payment is per admission. The insured might be required to pay a $500 copay, for instance. That means $500 each time the insured enters a rehab program.
Coinsurance fees are based on a percentage of the total bill. For example, a 30 percent coinsurance fee means the insured is responsible for 30 percent of the cost of treatment. If the bill comes to $5,000, the out-of-pocket expense would be $1,500.
Coinsurance fees for Avera might be anywhere from 30 to 40 percent. Plans with a large deductible may not require a copay or a coinsurance fee for inpatient treatment. For instance, the Avera 6550 plan will cover inpatient rehab in full after the deductible is met, as long as care is preauthorized and done at an in-network facility.
In-Network And Out-Of-Network Residential Addiction Treatment
In general, most of the Avera insurance plans allow for treatment at out-of-network facilities with a coinsurance fee of 40 percent. Preauthorization is necessary for both in-network and out-of-network treatment.
What Is Inpatient Rehab?
Inpatient rehab provides addiction treatment in a residential setting. This level of care allows individuals with an addiction to live in a safe environment along with others experiencing the same problem and going through similar treatment.
Through inpatient rehab programs, people experiencing an addiction can avoid common triggers as they work toward long-term sobriety.
Most inpatient care includes services such as:
- Initial assessment
- Medical exams
- Co-occurring Disorders
An initial clinical assessment will allow the treatment provider to look for other issues such as mental health problems that might be contributing to the addiction. Often someone entering drug rehab will suffer from an underlying mental health disorder such as depression, anxiety disorder or bipolar disorder. They may use drugs or alcohol as a way to self-medicate and relieve the symptoms of the disorder.
If a patient exhibits signs of a mental health disorder, a treatment plan for the co-occurring substance use disorder and mental health disorder will integrate therapy to address both issues simultaneously. By treating both the addiction and the mental health concern at once, treatment programs can reduce the risk of relapse and improve quality of life.
Does Avera Cover Outpatient Rehab?
As with inpatient care, the amount that Avera pays toward outpatient drug and alcohol rehab depends on many factors that include which Avera plan the insured carries. Typically, Avera outpatient treatment involves a copayment amount for office or facility visits. Other services require a coinsurance fee. Copays run from $25 to $50 or more per session.
Coverage for outpatient care is available for both in-network and out-of-network facilities. The amount Avera pays will be different for out-of-network treatment, though, and runs somewhere around 40 percent.
Outpatient treatment comes in many formats, including:
- Day programs that allow the patient to check in every morning and leave in the evening to stay with family or friends.
- Office visits for individual or group therapy
- Peer support groups
Does Avera Cover Medication-Assisted Treatment?
Avera plans may cover medication-assisted treatment for opioid addiction using prescription medications such as:
- Suboxone (buprenorphine, naloxone)
- Zubsolv (buprenorphine, naloxone)
- Bunavail (buprenorphine, naloxone)
Avera Health Plans works closely with partner facilities to provide innovative and effective addiction treatment options like MAT.
Does Avera Cover Sober Living Houses?
Avera Health has a commitment to aftercare services as part of their comprehensive drug and alcohol treatment. Avera may pay at least part of the cost of sober living houses. Coverage may depend on the exact policy and the facility.
Sober living houses give those transitioning from an addiction treatment program back to regular life a safe place to live and adjust to sobriety.
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What’s The Difference Between In-Network And Out-Of-Network?
In-network providers are the treatment centers that have a partnership with Avera. In-network facilities adhere to an agreed-upon pricing structure and file their claims directly with Avera to receive payment.
Out-of-network treatment centers do not have that same arrangement. Avera plans may cover up to 40 percent of treatment costs for out-of-network plans, though. In some cases, the facility may work with Avera to make direct payment arrangements or the insured may file the claim with Avera themselves.
How To Find Drug And Alcohol Rehab Centers That Accept Avera Health Plans
1) Contact Addiction Campuses for an immediate verification of benefits. Addiction Campuses can answer questions about insurance and addiction treatment and perform a no-obligation verification of insurance benefits on your behalf.
2) Contact the insurance provider by using the phone number on the back of the insurance card or by visiting the provider’s website. A representative will be able to match you to an in-network drug and alcohol rehab center.
3) Call the treatment center you or your loved one is interested in. The treatment center’s admissions team can answer questions about covered services.