Rehab Centers That Accept Harvard Pilgrim Insurance

Treatment for substance addiction can be life-saving, and you shouldn’t have to worry about how you’re going to afford care. Many Harvard Pilgrim Health Care policyholders use their insurance plan to help cover the cost of substance use disorder treatment and get the help they need. Coverage can vary significantly by policy, but understanding the basics of how Harvard Pilgrim insurance works and what plans are available can make finding affordable care easier.

Harvard Pilgrim Health Care is a health insurance company that operates under Point32Health along with its sister company, Tufts Health Plan. Originally founded by doctors, Harvard Pilgrim is a not-for-profit that serves more than 1 million members across New England, particularly in Massachusetts, New Hampshire, Maine and Connecticut.

Most Harvard Pilgrim insurance plans offer some type of coverage for alcohol and drug rehab. Harvard Pilgrim individual and family plans purchased through the Healthcare Insurance Marketplace are required to cover substance abuse and behavioral health treatment under the Affordable Care Act (ACA).

The Mental Health Parity and Addiction Equity Act (MHPAEA) also requires employer-sponsored and group plans to provide the same level of coverage for substance abuse and behavioral health services as they do for standard medical care. However, this means co-pays, coinsurance and deductibles would apply the same way, which is why you’re still likely to have out-of-pocket costs.

Harvard Pilgrim insurance covers a wide range of addiction treatment services, but coverage varies depending on your plan, the level of care and medical necessity. Below you’ll find a list of common treatment services and how Harvard Pilgrim Health Care insurance may apply.

Medical Detox

Medical detox is a rehab service that helps rid the body of addictive substances before starting a treatment program. Your care team helps you safely manage withdrawal symptoms, monitor your vitals and administer medications or treatments as needed.

Many Harvard Pilgrim insurance plans cover medical detoxification to some extent. You may have a co-pay for this service or be responsible for your coinsurance if you’ve already met your deductible.

Medication-Assisted Treatment

Medication-assisted treatment (MAT) is an evidence-based treatment method that treats certain substance use disorders with medications approved by the U.S. Food and Drug Administration (FDA). These medications, in combination with other treatment methods, can help reduce cravings and withdrawal symptoms and decrease the risk of relapse over time.

Most Harvard Pilgrim insurance plans cover medication-assisted treatment when it’s medically necessary. It’s sometimes called “rapid withdrawal relief” or “medication-assisted therapy” in plan documents. The actual medications are usually covered under your pharmacy benefits and may have a co-pay.

Inpatient Rehab

Inpatient care is a comprehensive program that provides 24/7 support while you live on-site at the facility. Harvard Pilgrim plans should cover at least part of inpatient rehab, according to the rules of the ACA and MHPAEA.

Many policies cover inpatient care based on coinsurance. This means you’re responsible for your yearly deductible, and once you’ve met it, the insurance will start cost-sharing. You’ll pay your coinsurance percentage, and the insurance covers the rest.

Dual Diagnosis Treatment

Dual-diagnosis programs treat mental illnesses, such as anxiety, depression, post-traumatic stress disorder (PTSD) and bipolar disorder, and substance use disorder at the same time. Therapy and counseling are often a big part of these programs.

Harvard Pilgrim covers dual-diagnosis treatment under mental and behavioral health benefits. Many people attend dual-diagnosis treatment as part of a larger inpatient or outpatient program. Your policy and the rehab’s network status will determine whether insurance covers treatment and what you’ll be responsible for.

Outpatient Treatment Programs

Outpatient treatment is often used as a step-down from inpatient care, but for some people, it’s the starting point. Harvard Pilgrim generally covers outpatient rehab, but you’ll likely have coinsurance or co-pay requirements, depending on how the program is structured. Some variations of outpatient treatment, such as intensive outpatient programs (IOPs) and partial hospitalization programs (PHP), may require prior authorization.

Counseling and Behavioral Therapy

Both behavioral therapy and counseling are common in substance abuse treatment. Counseling focuses on your feelings and emotions, while behavioral therapy, such as cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT), addresses your thoughts and actions.

Counseling and therapy are covered under mental health benefits. Many Harvard Pilgrim plans use a co-pay system, where you’ll pay a flat fee for each office visit.

Continuing Care

Continuing care, also called aftercare in many programs, refers to the services you continue to receive after completing rehab. Whether Harvard Pilgrim covers continuing care depends on the services.

Treatments you access through a licensed provider, such as ongoing therapy or MAT, are likely to be covered. Sober living usually isn’t because it’s considered a support and not a treatment.

Having insurance doesn’t mean you won’t have to pay anything for rehab treatment, but it does mean that your out-of-pocket costs are likely to be significantly less. Each policy has its own rules for how in- and out-of-network care are covered and what your deductible and coinsurance may be.

Factors to consider include:

• Your location: The state you live in affects your coverage because local laws and regulations vary. Additionally, individuals in different states have access to different insurance plans.
• Your plan: Some plans may cover more of your treatment costs than others. Each plan also has different co-pays, coinsurance, deductibles and premiums.
• Type of treatment: Many plans have different rules for inpatient and outpatient rehab. Outpatient therapy and MAT follow-up visits may be covered as office visits with a co-pay.

If you’re not sure what your plan covers or you have questions about certain services or treatments, you can talk to a Harvard Pilgrim representative who can explain your policy and verify your benefits.

Some Harvard Pilgrim health insurance plans will partially cover out-of-network rehab programs after you meet your deductible, while others only cover in-network care. The Summary of Benefits document for your specific policy will outline whether you can choose your own provider or if you have to stay within the Harvard Pilgrim network.

If your policy covers out-of-network providers, you’ll usually have to meet your deductible for the year before insurance pays anything. Even after your deductible, you’ll still be responsible for coinsurance, and the percentage you pay is likely to be higher than with in-network care.

The company offers a large variety of policy options for employer-sponsored plans, and national plans are available for those who need multisite or multistate coverage.

Standard plans offered by Harvard Pilgrim include:

• Health Maintenance Organizations (HMOs). These plans usually have the lowest premiums, but they only cover in-network care. You’ll generally need a referral from your primary care physician (PCP) to see a specialist.
• Preferred Provider Organizations (PPOs). These plans are more flexible, allowing you to access out-of-network care without referrals, but monthly premiums are higher.
• Point of Service (POS). These plans offer moderate premiums. You’ll usually need a referral for specialist care, but there’s some out-of-network coverage.
• Medicare. Harvard Pilgrim offers Medicare Supplement and Medicare Enhance plans to those who meet specific eligibility criteria.

Harvard Pilgrim also participates in the Massachusetts ConnectorCare program, which may be an option for low-income residents in that state.

Harvard Pilgrim doesn’t base coverage on the type of addiction you have. Whether addiction treatment services are covered depends on your official diagnosis and medical necessity.

Some common substance use disorders you may receive coverage for include:

• Alcohol
• Cocaine
• Heroin
• Meth
• Prescription drugs
• Opioids
• Benzodiazepines

Gambling disorder is also covered under behavioral health benefits because it’s a recognized mental health diagnosis. Treatment for non-substance addictions usually isn’t covered. If you’re not sure whether your addiction services will be covered, check with Harvard Pilgrim for more information.

Once you have a better understanding of your insurance plan and substance use disorder coverage, you’ll need to find a treatment center that accepts Harvard Pilgrim.

You can get more information and support from:

1. Your healthcare provider. If you’re seeing a medical provider for your addiction, they should be able to give you a list of rehab facilities that accept your insurance.
2. Harvard Pilgrim’s provider directory. Use the “Find a provider” function on Harvard Pilgrim’s website. Here, you’ll find in-network addiction treatment centers that are in your area.
3. RehabNet’s list of addiction treatment facilities. Our list is broken down by state and includes information on reputable rehab centers and which insurance companies they accept.

Many people who are insured through Harvard Pilgrim Health Care can use their coverage to make substance abuse treatment more affordable and get the help they need. If you’re ready to take the first step in your recovery journey, call our helpline today. We can connect you with top providers that accept Harvard Pilgrim insurance coverage.