Rehab Centers That Accept Ambetter Health Insurance

According to the Substance Abuse and Mental Health Services Administration’s 2024 National Survey on Drug Use and Health, around 80% of people who needed treatment for a substance use disorder didn’t receive it. While there are many reasons a person may not receive care, cost and affordability often play a role.

If you have Ambetter Health insurance, your policy covers at least part of the cost of addiction treatment. Specific coverage details depend on factors such as your tier level, location and provider network, and understanding how your benefits may apply to rehab can be a first step in finding a treatment facility that’s right for you.

Ambetter Health is one of the most common insurance providers in the ACA Marketplace and offers a variety of plan types and coverage levels across 29 states. More than 5.8 million people are covered by Ambetter Health insurance, and the company provides policies across three tiers: Bronze, Silver and Gold. Most Ambetter plans only offer in-network coverage unless there’s a medical emergency, but some may also provide limited coverage for out-of-network providers.

Ambetter Health insurance plans help cover the cost of drug and alcohol rehab and behavioral health treatment, as required by the Affordable Care Act (ACA) and Mental Health Parity and Addiction Equity Act (MHPAEA)

How much Ambetter Health insurance covers and what you could pay out of pocket depends on your specific plan. Verifying your benefits with Ambetter Health and the rehab before admission ensures you fully understand your coverage and the treatment you may be eligible for.

The number you call to verify Ambetter Health benefits for substance use disorder or behavioral health treatment is different depending on your state. Your number is on the back of your insurance card, or you can choose your state on Ambetter’s Contact Us page for more information.

Ambetter Health should cover medically necessary treatment for substance use disorder and any co-occurring mental health disorders. Benefits are generally available for both inpatient and outpatient settings, but there may be network restrictions or prior approval requirements.

Ambetter Health insurance covers detox services as long as they’re medically necessary. Some substances, such as alcohol, opioids and benzodiazepines, require close medical supervision during withdrawal, but Ambetter may still cover detox for other substances, especially if there are co-occurring health conditions that make withdrawal more dangerous.

Depending on your plan, you may need a referral for detox services from your primary care provider (PCP) and/or prior authorization before Ambetter will cover detox. You may also be required to go through detox at an in-network facility.

Inpatient rehab, or residential treatment, means that you’re living at the facility full-time while you go through the program. Ambetter Health covers inpatient services for mental and behavioral health, including treatment for substance use disorder, but network requirements and coinsurance generally apply.

Many Ambetter plans require prior authorization. Not getting preapproval or attending an out-of-network rehab if your plan doesn’t cover it could mean you’ll end up paying the bill. Verifying your benefits ensures you know what you need to do before choosing and checking into a program.

When you attend an outpatient treatment program, you visit a facility several times a week for services instead of living on-site. Most Ambetter plans require you to attend outpatient treatment at an in-network provider. This includes intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs).

Some policies may require you to meet your deductible before coverage kicks in for outpatient treatment, and coinsurance may apply. This means you’ll split the program cost with the insurance company, according to the percentages outlined in your Summary of Benefits statement, until you reach your out-of-pocket max for the year.

Medication-assisted treatment involves the use of FDA-approved medications to treat and manage opioid use disorder and alcohol use disorder. The medications used in MAT can help manage withdrawal symptoms and cravings and reduce the effects of addictive substances.

Ambetter Health’s coverage for MAT may come from both medical benefits and pharmacy benefits. There may be rules about which medications are covered or which formularies you must use, and you may need prior authorization.

You can find information on how Ambetter Health insurance covers medications for substance use disorder in its Formulary/Prescription Drug List. These are state-specific, and a center offering MAT can help you verify your benefits.

Therapy and counseling can teach you to identify your triggers and the thoughts and behavior patterns behind addiction. You’ll learn new coping skills and develop strategies for what to do if you have a stressful day or want to use.

Ambetter Health insurance policies cover therapy and counseling under mental health services. If these are part of a comprehensive rehab program, they may be included in that cost-sharing. If you’re accessing them on an outpatient basis or as part of aftercare, you’ll likely have a co-pay, which is the amount you pay for every office visit.

Many plans require you to have prior authorization and/or a specific mental health diagnosis, including substance use disorder, for therapy and counseling to be covered. Ambetter also typically only covers evidence-based care, such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT).

As for counseling, individual and group settings are typically offered in rehab programs. Individual counseling can be a great opportunity to discuss your goals, fears, and progress. As for group counseling, you’ll have an opportunity to connect with peers and hear their experiences with addiction.

According to data from the Substance Abuse and Mental Health Services Administration, around 45% of adults with a substance use disorder also had a mental illness. Dual-diagnosis programs are designed to address both simultaneously and can include everything from medication management and psychiatric evaluations to behavioral therapy and outpatient care.

Because treatment for dual diagnosis can involve a range of services, understanding Ambetter Health coverage can be challenging. Ambetter only covers medically necessary care, and the cost-sharing structure varies by policy and plan tier.

Medications will likely be covered according to your state’s formulary rules, and out-of-network treatment isn’t available for most plans. Prior authorization is usually required for higher levels of care, including inpatient treatment and partial hospitalization programs.

Aftercare, also called continuing care, happens after you complete a treatment program. Continuing care could involve ongoing therapy, peer support group meetings and sober living arrangements.

Whether Ambetter Health insurance covers aftercare services depends on the type of treatment. Counseling and therapy are covered under mental health benefits, but some services, such as sober living, aren’t usually covered.

Factors that can impact Ambetter Health’s rehab insurance coverage include:

• Type of insurance plan. The majority of Ambetter plans are Health Maintenance Organizations (HMOs) or Exclusive Provider Organizations (EPOs). These plans usually only offer in-network coverage. The insurance company offers limited Preferred Provider Organization (PPO) or Point of Service (POS) plans in some states that may cover out-of-network substance abuse treatment.
• Your location. Ambetter Health offers different plans for each location based on state regulations. How much of rehab is covered and what restrictions there are depend on where you live.
• The rehab’s network status. Ambetter Health covers a larger portion of the cost of care at in-network facilities. Out-of-network providers may not be covered at all or may have much higher cost-sharing requirements.
• Prior authorization and medical necessity requirements. You may need a doctor to state that the treatment is medically necessary, and the facility may need to submit a prior authorization request before Ambetter Health will pay.

How much you could end up paying out of pocket also depends on cost-sharing for your plan, which includes:

• Co-pay: A fixed amount that you pay per visit or treatment
• Deductible: How much you have to pay out of pocket before the insurance company will start covering your care
• Coinsurance: The percentage of the cost you have to pay even after you’ve met your deductible

Your plan will also include an out-of-pocket maximum for the year. Once you’ve met this, the insurance company pays 100% of any additional treatment costs that are covered under your plan.

Ambetter Health doesn’t cover out-of-network nonemergency services if you have an HMO or EPO plan. If you have a PPO or POS plan, you may have limited out-of-network coverage for drug and alcohol abuse treatment.

In-network providers are those who are contracted with Ambetter Health to offer lower treatment costs. Out-of-network providers aren’t contracted with Ambetter Health, so they don’t offer discounted rates, which means you may be covering a large portion of, or even the entire, bill. Some facilities also offer payment plans, sliding-scale fees and other financial assistance.

Ambetter Health offers both individual and family plans and has three tiers of insurance:

• Ambetter Essential Care (Bronze): Bronze plans have lower monthly premiums but may have very high deductibles, resulting in higher out-of-pocket costs.
• Ambetter Balanced Care (Silver): These plans balance monthly premium payments and out-of-pocket costs.
• Ambetter Secure Care (Gold): Gold plans have higher monthly premiums, but your deductible and out-of-pocket maximum are likely to be much lower than with other tiers. This can significantly reduce your total out-of-pocket costs, especially if you have conditions that require frequent treatment.

Ambetter Health also offers the following types of plans in select states:

• Ambetter Health Premier: These plans offer the broadest provider network, cover essential health services and don’t require referrals.
• Ambetter Health Select: Offered exclusively in Georgia, these plans have affordable premiums, but the provider network is much smaller.
• Ambetter Health Value: Value plans offer access to a network of providers and assign members a primary care physician (PCP). They often have the lowest premiums, but specialty services require referrals. These plans are offered in Texas and Florida.
• Ambetter Health Solutions: These plans are intended for individuals purchasing health insurance through defined contribution or health reimbursement arrangements, such as an individual coverage health reimbursement arrangement (ICHRA) or a qualified small employer health reimbursement arrangement (QSEHRA). They’re offered in 12 states, including Arizona, Florida, Georgia, Indiana, Kansas, Mississippi, Missouri, Ohio, Oklahoma and South Carolina.

Because there are so many differences between plans, it’s a good idea to review your Summary of Benefits statement and verify your coverage with Ambetter and the treatment facility.

Ambetter Health insurance provides at least partial coverage for most substance use disorders, including:

• Alcohol
• Stimulant
• Opioids
• Heroin
• Methamphetamine
• Prescription drugs

Ambetter’s coverage for substance abuse disorder depends on whether the treatments are medically necessary and evidence-based. Your healthcare provider will do a clinical assessment to determine how substance use is affecting your mental and physical health and recommend appropriate treatments.

Finding a treatment center that accepts your insurance and offers the treatments and amenities you need can feel overwhelming. However, there are several easy ways you can find a rehab center that accepts Ambetter Health:

• Use Ambetter’s provider directory. When you log in to your online member account, you can use the provider directory to find in-network addiction treatment centers. You can filter by provider type, treatment type and distance from your home. Once you find one you’re interested in, you can reach out to get more information.
• Call rehab facilities. If you find a treatment center but aren’t sure whether they accept your insurance, you can always call to confirm whether they’re in-network with your provider. Many rehab centers offer free insurance verification to help you understand your benefits and expected out-of-pocket costs.
• Browse RehabNet.com’s list of treatment centers by state. Each list includes some of the top-rated treatment centers in the state, along with information on accepted insurance plans and treatment offerings.

You may need to meet certain requirements before your Ambetter plan covers your substance abuse treatment. Talk with a representative to confirm whether you need prior authorization, a referral or an official diagnosis before enrolling in a program.

If you or your loved one needs addiction treatment, concerns about cost shouldn’t keep you from seeking help. Ambetter Health insurance plans cover addiction rehab and substance use treatment, but the amount of coverage depends on several factors. Call our helpline today to learn how to verify insurance coverage and find the right treatment center for you.