CareFirst Insurance Coverage for Rehab

A subsidiary of Blue Cross Blue Shield, CareFirst BlueCross BlueShield began in 1934 and offers extra support resources for behavioral health and addiction.

CareFirst covers members in Maryland, Washington, D.C., and Virginia, including members of Congress. If you live in the Mid-Atlantic region, you may have a CareFirst insurance plan through your employer or the Healthcare Insurance Marketplace.

To find out more about your insurance benefits through CareFirst for substance use disorder treatment, read on.

Answer: Yes, most CareFirst plans offer coverage for drug rehab, even those purchased privately.

While insurance companies are not required to follow the Affordable Care Act (ACA) guidelines for plans sold outside the Healthcare Insurance Marketplace, CareFirst maintains that all plans are ACA-compliant.

You may have out-of-pocket costs, like copays and coinsurance. You may also have deductibles to meet before health services are covered with your CareFirst insurance plan.

Answer: CareFirst covers all types of addiction treatment, as they are compliant with the ACA’s 10 essential benefits. Coverage for behavioral health and substance use disorder treatment is included in all plans.

Here are the types of addiction rehab programs and services you can access with CareFirst health plans, depending on your individual policy.

Medical Detox

Talk to your primary care provider about whether you need to go through a medical detoxification and if it should be done as an inpatient or outpatient treatment.

Then, check your CareFirst policy for what percentage of treatment services your health plan covers. Your metal type (Bronze, Gold, Silver, Platinum) will determine your coinsurance percentage, copays, and deductibles.

Bronze and Silver plans in Washington, D.C., use a straight coinsurance formula for outpatient surgery and inpatient services.

Medication-Assisted Treatment

For medication-assisted treatment (MAT), know that CareFirst offers a range of options based on your plan. Inpatient treatment may be billed under those services.

MAT is a common form of opioid and alcohol treatment that combines medications to treat withdrawal symptoms and counseling and behavioral therapy to address the addiction

Prescription coverage under CareFirst can be any of the following:

• Copay
• Copay and deductible
• No charge after deductible
• No charge, no deductible
• No out-of-pocket maximums

If you need prescription drugs on a continuing basis, you’ll need to know what tier level each falls under. If you want non-generic, understand that your out-of-pocket costs will be higher if there’s a generic option available.

Inpatient Rehab

Because CareFirst is ACA-compliant, inpatient rehab must match other inpatient services. In D.C., Bronze and Silver plans have a straight coinsurance percentage, while all other plans and locations vary copays, deductibles, and coinsurance.

Inpatient services at a hospital also mean that you’ll have a bill for the hospital, the doctor, and lab services. These services are usually billed separately. LabCorp is the only in-network treatment provider for CareFirst HMO labs.

Dual Diagnosis Treatment

If you’ve been told by your healthcare provider that you have a mental health disorder and a substance use disorder, then you’ve received a dual diagnosis.

CareFirst has a specific section in each explanation of benefits (EOB) that covers what your financial responsibility is for mental health and SUD treatment office visits under your treatment plan.

These co-occurring disorders can be treated in a few different ways, so it’s essential to determine how your insurance covers your treatment plan.

Outpatient Treatment Programs

Outpatient treatment with CareFirst is not addressed explicitly in the EOBs. Still, it may fall under the outpatient surgery section (as an ACA coverage match) and office visits for SUD and mental health treatment.

Check your individual plan through CareFirst’s member login or by calling the number on your insurance card to go over your treatment options.

Counseling & Behavioral Therapy

As part of the 10 essential benefits under the ACA, behavioral health treatment coverage is included in every CareFirst insurance plan. Your plan’s metal type will affect your out-of-pocket costs, as will any employer assistance program (EAP) sessions.

Continuing Care

Because treatment for drug and alcohol addiction continues after rehab, so should insurance coverage. Mental health and substance use disorder office visits have a clearly defined row in CareFirst’s EOB.

Your plan may have a copay or coinsurance charge. Or, you may have to meet your deductible before insurance will pay for those treatment options.

Many things factor into whether a recovery center or outpatient care will be covered by your CareFirst plan.

These factors can affect whether services are covered and what your out-of-pocket expenses are:

• Location – Treatment can take place anywhere, but CareFirst is only for residents of Maryland, Washington, D.C., and Northern Virginia, and members of Congress. Where you’re treated can be negatively impacted by in-network status, though urgent, convenient, and emergency care treatment facilities are primarily exempt from this.
• Metal type – There are four metal types, each covering a set percentage of costs for coinsurance. Your out-of-pocket expenses for copays and meeting deductibles will be determined by metal types as well.
• Plan type – For example, HMO plans will only cover lab services performed by LabCorp and diagnostic and imaging services from freestanding facilities.
• Family size – This comes into play with your deductible and its setup. If a loved one has met their deductible, but a different family member requires treatment, that deductible responsibility may only be reduced by the percentage completed by the other family  member. The member undergoing treatment may still have to meet their deductible percentage to significantly decrease overall costs.

Answer: On every plan except HMOs, CareFirst covers treatment by out-of-network providers. However, you will pay more for treatment out of pocket.

If you require care at an urgent care center, convenient care, or emergency department while traveling, that is more likely to be covered by CareFirst.

CareFirst healthcare plans are available in multiple forms and vary by state. All subsidies with CareFirst are independently licensed by the Blue Cross and Blue Shield Association.

Metal levels are:

• Bronze (Maryland and Washington, D.C. only)
• Silver
• Gold
• Platinum (Washington, D.C. only)

Plan types are:

• Health Maintenance Organization (HMO)
• Point of Service (POS)
• Preferred Provider Organization (PPO)
• Catastrophic Plan (including BlueChoice HMO Young Adult Plan)
• CareFirst Medicare Advantage
• CareFirst MedPlus
• CareFirst Medicaid (Maryland and Washington, D.C. only)

Maryland plans for 2024 include:

• BlueChoice HMO HSA Bronze
• BlueChoice HMO Value Bronze
• BluePreferred PPO Value Bronze
• BlueChoice HMO Value Silver
• BluePreferred PPO Value Silver
• BlueChoice HMO Value Gold
• BlueChoice HMO Gold
• BluePreferred PPO Value Gold
• BlueChoice HMO Young Adult

Washington, D.C. plans for 2024 include:

• BlueChoice HMO Standard Bronze
• BluePreferred PPO Standard Bronze
• BlueChoice HMO HSA Standard Bronze
• BluePreferred PPO HSA Standard Bronze
• BlueChoice HMO Standard Silver
• BluePreferred PPO Standard Silver
• BlueChoice HMO Standard Gold
• BluePreferred PPO Standard Gold
• BlueChoice HMO HSA Gold
• BluePreferred PPO HSA Gold
• BlueChoice HMO Standard Platinum
• BluePreferred PPO Standard Platinum
• BlueChoice HMO Young Adult

Virginia plans for 2024 include:

• BlueChoice HMO Standard Silver
• BluePreferred PPO Standard Silver
• BlueChoice HMO HSA Silver
• BluePreferred PPO HSA Silver
• BlueChoice HMO Gold
• BluePreferred PPO Gold
• BlueChoice HMO Standard Gold
• BluePreferred PPO Standard Gold
• BlueChoice HMO Young Adult

Members of Congress and their staff can choose from national and regional plans. National plans provide coverage for over 90% of American doctors and hospitals. Regional plans offer care in the local coverage areas.

Regional plan options for 2023 include:

• BlueChoice Plus Gold
• BlueChoice HMO Referral Gold
• BlueChoice HMO Standard Gold
• BlueChoice HMO Gold
• BlueChoice HMO HSA/HRA Gold

National plan options for 2023 include:

• BluePreferred PPO Standard Gold
• BluePreferred PPO Gold
• BlueChoice Advantage Gold
• BlueChoice Advantage HSA/HRA Gold

CareFirst covers all types of addiction treatment, including treatment for:

• Opioids
• Stimulants
• Alcohol
• Depressants
• Inhalants
• Hallucinogens
• Nicotine

To locate rehab centers that are in-network for your CareFirst health insurance plan, you have a few options.

You can find rehab facilities that accept CareFirst by:

1. Logging into your member site and searching for an appropriate facility nearby.
2. Calling the number on the back of your card, which will allow you to speak to a CareFirst representative.
3. Visiting the CareFirst website and using the Find a Doctor feature.
4. Hopping on RehabNet.com and exploring our list of facilities in your area.

CareFirst also has a PDF of opioid treatment resources available through its website.

This list of resources includes:

• Residential treatment centers (RTC)
• Intensive outpatient programs (IOP)
• Office-based opioid treatment (OBOT)
• Opioid treatment partners
• Additional resources by county

Figuring out the ins and outs of your insurance provider is a lot to handle. And when you’re trying to break the cycle of drug addiction or alcohol dependency, you have enough obstacles.

Let RehabNet.com tackle this one. Visit our website or call our helpline anytime, day or night. We can provide information on accredited treatment centers near you.