Does Aetna Cover Both Inpatient and Outpatient Rehab?
Aetna plans generally cover both inpatient and outpatient rehab, which aligns with the Affordable Care Act’s requirement to cover substance use disorder services. Coverage generally includes programs like medically supervised detox, residential stays, and various forms of Aetna outpatient rehab, such as Intensive Outpatient Programs (IOP).
However, the extent of your coverage, including copays, deductibles, and any pre-authorization requirements, depends on your specific plan, as well as which level of care is deemed medically necessary. It is best to verify your benefits with Aetna or the admissions team at a treatment facility before starting treatment to understand your coverage and minimize out-of-pocket costs.
Table of contents
» Does Aetna Cover Medication-Assisted Treatment (MAT) for Addiction?
» Does Aetna Provide Coverage for Dual Diagnosis or Co-Occurring Disorders?
» What Out-of-Pocket Costs Should I Expect With Aetna Rehab Coverage?
» What Should I Do if Aetna Denies My Rehab Coverage?
» Key Takeaways on Aetna Outpatient Rehab
» Resources
Does Aetna Cover Medication-Assisted Treatment (MAT) for Addiction?
Medication-Assisted Treatment (MAT) is an evidence-based approach that combines FDA-approved medications with counseling and behavioral therapy to address substance use disorders. This comprehensive approach to treating substance use disorders is a key component of many inpatient and outpatient rehab programs, particularly opioid use disorder (OUD) and alcohol use disorder (AUD).
MAT can significantly improve recovery outcomes as it helps to:
- Reduce withdrawal and cravings, stabilizing patients both physically and mentally.
- Improve treatment retention, as people in MAT programs are more likely to stay engaged in treatment.
- Lowers the risk of relapse and overdose.
Aetna recognizes the medical necessity of MAT and typically covers it as part of insurance coverage for drug rehab. In many addiction treatment settings, MAT is integrated into inpatient/residential care, especially when withdrawal must be medically managed during detox.
Aetna often covers these medications as part of the inpatient stay, which can include buprenorphine, Naloxone, Naltrexone, and Methadone, as well as stabilizing medications like benzodiazepines, anticonvulsants, and blood pressure medications.
Aetna outpatient rehab with MAT is more commonly covered under their behavioral health benefits. However, as with any other addiction treatment, coverage depends on your specific plan, whether MAT is deemed medically necessary, and may require prior authorization. Coverage may also differ based on whether the facility is in-network or out-of-network with Aetna.
Does Aetna Provide Coverage for Dual Diagnosis or Co-Occurring Disorders?
Dual diagnosis refers to the presence of both a mental health disorder and a substance use disorder, which is also known as co-occurring disorders. The symptoms of one condition can exacerbate the symptoms of another condition, and vice versa.
In these cases, treating just one issue in isolation often leads to relapse or incomplete recovery. Aetna, like most major insurers, recognizes the importance of integrated treatment, which means addressing both conditions together through coordinated care. It typically covers dual diagnosis treatment.
Aetna may cover dual diagnosis services in both inpatient and outpatient settings. The key is to find drug rehabs that accept Aetna insurance and offer integrated care. Many treatment centers that accept Aetna are equipped to deliver dual diagnosis services under a single, comprehensive care plan.
This often includes a mix of medical detox, psychiatric evaluation, medication management, therapy, and relapse prevention. However, coverage can vary based on several factors, including your plan type, whether the facility is in-network, medical necessity, and pre-approval from Aetna.
What Out-of-Pocket Costs Should I Expect With Aetna Rehab Coverage?
Under the Affordable Care Act (ACA), most health plans, including those offered by Aetna, are required to cover substance use disorder services as essential health benefits. However, even with coverage, members will be responsible for certain out-of-pocket costs, including:
- Deductibles: This is the dollar amount you must pay out of pocket for covered medical services each year before Aetna starts paying a larger share of the costs. In the cost of residential rehab or inpatient detox, you will likely pay a significant portion of your annual deductible before your full benefits kick in.
- Coinsurance: After you have met your deductible, you may still be responsible for a percentage of the bill known as coinsurance. The most common coinsurance is 20%, meaning Aetna pays 80% of the bill, and you pay 20%.
- Copayment: A fixed, flat fee you pay for specific services. Copays are most common for lower levels of care, such as for Aetna outpatient rehab therapy or counseling sessions.
It is essential to note that selecting an in-network rehab provider with Aetna can significantly reduce your out-of-pocket expenses. In-network providers have a contract with Aetna for prenegotiated rates, and your share is based on those reduced fees.
Conversely, out-of-network providers can charge you the remaining balance not covered by Aetna’s allowed amount, resulting in surprise costs. Moreover, those additional costs from billing balancing do not count toward your deductible. Verifying your insurance directly with Aetna or with the rehab center’s admissions teams can provide you with exact figures based on your plan and remaining deductible.
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What Should I Do if Aetna Denies My Rehab Coverage?
If Aetna denies your rehab coverage, there are several steps you can take to challenge the decision and potentially get insurance to pay for inpatient rehab or other treatment services. Your primary course of action is to follow Aetna’s structured appeal process:
- Request the denial in writing: This should include the reason for denial, such as lack of medical necessity, missing preauthorization, or the rehab facility is out-of-network.
- Ask the rehab center for help: Many reputable treatment facilities have insurance advocates who can assist you in appealing the denial and gather supporting documents, such as clinical records and a letter of medical necessity.
- File an internal appeal: You have the right to appeal Aetna’s decision. Submit medical records, letters from your doctor, and a statement explaining why the treatment is necessary.
- Request an Expedited Appeal: If you are currently in treatment or need urgent care, you or your provider can request an Expedited Appeal, which Aetna must resolve more quickly, sometimes within 72 hours.
- File an external review: If Aetna upholds the denial, you may request an independent third-party review. If the reviewer overturns the decision, Aetna must cover the treatment.
Key Takeaways on Aetna Outpatient Rehab
- Aetna Generally Covers Both Inpatient and Outpatient Rehab: Aetna plans typically include coverage for both inpatient and outpatient rehab services as mandated by ACA requirements. This may consist of detox, residential treatment, and Aetna outpatient rehab options like PHP and IOP.
- Medication-Assisted Treatment (MAT) is Often Covered: Aetna usually covers MAT in both inpatient and outpatient settings, particularly for opioid and alcohol use disorders. Coverage can include medications like buprenorphine, methadone, and naltrexone alongside therapy and counseling.
- Dual Diagnosis Treatment is Typically Included: Aetna also covers treatment for co-occurring mental health and substance use disorders through integrated care that may include psychiatric evaluations, therapy, and medication management.
- Expect Out-of-Pocket Costs: Even with coverage, you’ll likely face deductibles, coinsurance, and copays, and costs are significantly lower when using in-network providers.
- You Can Appeal If Coverage Is Denied: If Aetna denies your rehab coverage, you have the right to file an internal appeal and possibly requisition an expedited or external review.
WhiteSands Treatment is a network of Aetna in-network drug and alcohol rehab facilities in Florida, providing high-quality, comprehensive care with lower out-of-pocket costs for you and your loved ones. Our experienced admissions team can help you verify your insurance, explain your benefits, and obtain prior authorization on your behalf. We offer medical detox, inpatient rehab, outpatient programs, MAT, and dual diagnosis services to create a personalized treatment plan that can fit your needs and insurance plan coverage.
Contact WhiteSands Treatment today at 877-855-3470 to learn more about your Aetna coverage and take the first step toward lasting recovery.
Resources
- Centers for Disease Control and Prevention (CDC) – Medication-Assisted Treatment for Opioid Use Disorder
- Cleveland Clinic – Dual Diagnosis
- Aetna – Disputes and appeals process
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.
About the Author
Jackie has been involved in the substance abuse and addiction treatment sector for over five years and this is something that she is truly eager about. She has a passion for writing and continuously works to create informative pieces that not only educate and inform the public about the disease of addiction but also provide solutions for those who struggle with drug and alcohol abuse.
