What Should You Know About Wellpoint Insurance Coverage for Addiction?

Wellpoint insurance plans, which are now part of Elevance Health, frequently provide coverage for addiction treatment, encompassing both inpatient and outpatient services. Nonetheless, the Wellpoint insurance rehab coverage can differ based on the plan, the treatment type, and the facility involved. It is essential to review your individual Wellpoint policy and confirm your benefits to grasp what is included and what restrictions may exist. Furthermore, it is vital to recognize that pre-authorization might be required before commencing specific treatments, particularly for residential care.

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Table of contents

» Does Wellpoint Insurance Cover Addiction Treatment?

» How Can You Check Your Wellpoint Benefits for Substance Use Treatment?

» Do You Need Pre-Authorization for Rehab with Wellpoint?

» What Should You Do If Your Addiction Treatment Claim Is Denied by Wellpoint?

» Key Takeaways From Wellpoint Insurance Rehab Coverage

» Resources

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Does Wellpoint Insurance Cover Addiction Treatment?

The Affordable Care Act (ACA) mandates that health insurance providers, such as Wellpoint, include coverage for mental health and substance use disorder services, which encompass addiction treatment, as stated by HealthCare.gov.

Specifically, the ACA prohibits insurance companies from denying coverage or charging higher premiums for individuals with pre-existing conditions like substance use disorders. Wellpoint offers a diverse array of health insurance options, such as Medicaid, Medicare, and individual/family plans available through the ACA Marketplace, indicating that they are likely to provide a wide range of services for substance use disorders, which include:

• Inpatient Treatment: Residential care for detoxification and rehabilitation.
• Outpatient Programs: Including Intensive Outpatient Programs (IOP) and Partial Hospitalization Programs (PHP).
• Medication-Assisted Treatment (MAT): Use of FDA-approved medications like methadone, buprenorphine, and naltrexone to treat opioid and alcohol use disorders in combination with counseling.
• Behavioral Therapies: Individual, group, and family counseling.
• Dual Diagnosis Treatment: Integrated treatment programs that address substance use disorders and co-occurring mental health disorders simultaneously.
• Aftercare Services: Support following primary treatment to maintain recovery, including continued counseling, support groups, and medication management.

Wellpoint offers plans with both in-network and out-of-network coverage. Staying within their network generally lowers out-of-pocket costs, such as deductibles, copayments, and coinsurance. Some plans may allow out-of-network treatment, but with higher costs due to deductibles and copays for addiction treatment. Coverage can vary depending on length of stay, specific services, your Wellpoint plan, and the state you live in.

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How Can You Check Your Wellpoint Benefits for Substance Use Treatment?

Confirming your Wellpoint insurance rehab coverage is essential to understand your out-of-pocket expenses in advance, which helps avoid unexpected bills and financial strain. This verification also ensures that the specific addiction treatment services you require are included, as insurance plans can differ.

Although navigating insurance benefits may seem daunting, grasping what is covered, how to access treatment, and what to bring to drug rehab can significantly ease the recovery journey, allowing you to focus entirely on your treatment program.

Before you verify your benefits, first locate your Wellpoint insurance card, as you will need the member ID and possibly a group number. There are multiple methods to check your Wellpoint benefits for substance use treatment, including:

• Log In to Your Wellpoint Member Portal: Wellpoint provides a secure online member portal that contains a wealth of information about your plan. Here, you can view your summary of benefits, which details what your plan covers, including mental health and substance use disorder benefits. Furthermore, you can utilize their “Find Care” tool to locate addiction treatment centers and providers within your Wellpoint network. Ensure you understand your out-of-pocket responsibilities, such as deductibles, coinsurance, and copays.
• Call the Member Services Number: One of the most straightforward ways to check your benefits is by calling the Wellpoint member services number found on your insurance card. A Wellpoint representative can inform you about what your policy covers, what out-of-pocket expenses you might face, whether prior authorization is necessary, and referrals to in-network facilities. According to Wellpoint, knowing which providers your plan will help pay for is essential, as utilizing these in-network doctors and health centers can lead to significant savings.
• Contact Treatment Centers Directly: Many reputable rehabilitation facilities have an admissions or financial team experienced in working with insurance. They can contact Wellpoint on your behalf to verify benefits specifically associated with their treatment center and communicate that information back to you, making the complex language of insurance policies easier to understand. This approach also enables you to ask about their treatment programs, and they can initiate the preauthorization process, too.

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Do You Need Pre-Authorization for Rehab with Wellpoint?

In general, Wellpoint insurance requires pre-authorization for rehab coverage, which is also referred to as prior authorization or precertification. According to the National Association of Insurance Commissioners, this process necessitates that your doctor or provider secures your health plan’s approval before delivering health care services. If pre-authorization is not obtained, your health plan may refuse to cover your treatment, except in cases of emergency care.

Like many insurance providers, Wellpoint mandates pre-authorization to verify that the treatment is medically necessary and suitable for your particular condition. This process ensures that the services you receive are in accordance with clinical guidelines and are included in your plan’s coverage. Typically, this requirement applies to various levels of rehab care, including inpatient or residential treatment, PHP, IOP, medically supervised detox, and specific medications for substance use disorders.

Usually, your doctor or the addiction treatment facility will manage the pre-authorization process for you. They will send the required clinical details, such as diagnosis and treatment plan, to Wellpoint for evaluation.

Wellpoint’s clinical team will then assess the plan and decide whether the treatment qualifies for coverage, ultimately either approving or denying approval. Securing pre-authorization is vital before starting any rehab program to ensure your treatment is financially covered and to prevent unforeseen financial challenges.

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What Should You Do If Your Addiction Treatment Claim Is Denied by Wellpoint?

If your Wellpoint insurance rehab coverage is turned down, it doesn’t necessarily mean it’s the end of the road. The National Association of Insurance Commissioners states that you have the right to contest your health plan’s denial of benefits for covered services through either an internal appeal or an external review.

There’s a straightforward process to challenge their decision, and here’s what you need to do:

1. Understand the Denial: Carefully read the denial letter to pinpoint the exact reason, including being deemed not medically necessary, lacking prior authorization, the facility being out-of-network, or a clerical mistake.
2. Gather Documentation: The treatment facility can assist you with collecting the denial letter, pertinent medical records, pre-authorization requests, and responses.
3. Initiate Internal Appeal: Submit an appeal to Wellpoint within the designated time frame. Clearly express your disagreement, reference the claim details, explain why the decision is wrong, and include all supporting documents.
4. Pursue External Review: If the internal appeal is rejected, request an external review by an independent third party and reach out to your state’s Department of Insurance or the designated Independent Review Organization (IRO).

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Key Takeaways From Wellpoint Insurance Rehab Coverage

• Wellpoint Provides Coverage for Addiction Treatment: Wellpoint insurance rehab coverage typically includes a range of substance use disorder therapies and services, including inpatient and outpatient options.
• In-Network vs. Out-of-Network: Choosing in-network providers reduces out-of-pocket expenses, such as copayments and coinsurance.
• Pre-Authorization is Often Necessary: For numerous addiction treatment services, particularly residential care and medical detox, obtaining pre-authorization is essential to minimize the chances of your claim being rejected.
• Verifying Coverage is Crucial: Prior to starting treatment, it’s important to confirm your benefits directly with Wellpoint or through your selected treatment facility to understand deductibles, copays, coverage limits, and any pre-authorization requirements.
• Appealing Denials is Possible: If your claim is denied, you have the right to submit an internal appeal to Wellpoint and, if necessary, request an external review by an independent third party.

If you or someone you care about is facing addiction and wants to check if your Wellpoint insurance covers drug rehab, WhiteSands Treatment can assist in verifying your coverage. Our knowledgeable admissions team has extensive experience working with major insurance providers, including Wellpoint. Clinicians can create a tailored treatment plan based on your coverage and handle any preauthorization needs. Furthermore, we provide payment plans to help cover any services not included in your plan or for those without insurance.

Contact WhiteSands Alcohol and Drug Rehab today at 877-855-3470 to verify your Wellpoint insurance coverage or to find out more about our financing options.

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External Resources

• HealthCare.gov – Mental health & substance abuse coverage
• Wellpoint – Knowing your health plan’s network
• National Association of Insurance Commissioners – What is Prior Authorization?
• National Association of Insurance Commissioners – How to Appeal Denied Claims

If you or a loved one needs help with abuse and/or treatment, please call the WhiteSands Treatment at (877) 855-3470. Our addiction specialists can assess your recovery needs and help you get the addiction treatment that provides the best chance for your long-term recovery.