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Published: December 16, 2023
If you or a family member is a member with Wellmark BCBS Iowa and is seeking substance abuse treatment, you may be wondering if your addiction treatment will be covered.
Wellmark Blue Cross Blue Shield Iowa is one of the leading health insurance providers throughout Iowa and South Dakota. It has more than 2 million members currently and official NCQA-accreditation.
Read on to learn more about the type of substance abuse treatment coverage you can expect with Wellmark and the factors that could affect your coverage.
Answer: Yes, Wellmark BCBS Iowa does cover drug and alcohol rehab, although certain conditions must be met in order for this coverage to apply.
Wellmark Insurance covers alcohol and drug use treatment that is deemed to be medically necessary. The standards for coverage can vary by health plan but may include factors such as if a person has a high risk for relapse.
In order to receive coverage for certain types of addiction treatment, you must have prior authorization and a referral from your primary care physician that confirms the treatment is medically necessary.
Wellmark BCBS Iowa covers a variety of substance abuse treatment services, but specifically those which are found to be medically necessary.
Remember that the services listed here are covered by Wellmark Insurance, but the amount of coverage will vary. Policyholders may still be responsible for copays or partial payments.
Medically monitored detox involves using approved medications under a doctor’s supervision to taper off a substance at a rate that is comfortable and results in minimal withdrawal symptoms.
Medical detox is a service that would be covered as medically necessary under Wellmark, as withdrawal from some substances, such as alcohol, can be a life-threatening health condition without medical support.
Medication-assisted treatment (MAT) uses medications to make the withdrawal process more comfortable, but does so over a prolonged period of time, usually several weeks or months.
MAT is considered the standard of care when treating opioid use disorders, and this would be a service that is considered medically necessary and covered by Wellmark.
Inpatient rehab, also known as residential rehab, allows a person to stay onsite while receiving treatment and therapy, all with 24/7 supervision and monitoring. This type of treatment can be short-term (under 30 days) or long-term.
Wellmark will cover inpatient treatment as medically necessary for people who have a high risk of relapse and who have already tried outpatient treatment and relapsed.
Inpatient treatment for substance abuse or mental health services is one of the services that requires a prior authorization from your primary care physician before you can begin treatment.
Dual diagnosis treatment is a type of treatment offered when people have co-occurring disorders along with their substance use disorder, such as depression or post-traumatic stress disorder (PTSD).
This type of treatment is common, as it is estimated that roughly one in five American adults is living with some form of mental illness.
although if used in an inpatient setting, prior authorization would be required.
Dual diagnosis treatment is covered at least partially with Wellmark, Also, dual diagnosis treatment often requires the use of prescription drugs, the coverage for which will depend on a person’s insurance plan, the prescription drug benefits, and drug list that is offered under their specific Blue RX option.
The Blue RX drug list includes the FDA-approved generic and brand-name drugs for Wellmark policyholders, including specialty drugs, that are covered under its plans.
Many of the treatments involved in substance abuse treatment, including therapy and MAT, can be accessed in an outpatient setting. Outpatient treatment allows the person to continue with their normal lives if they have a family or other responsibilities.
Outpatient treatments are covered by Wellmark, as long as they are deemed to be medically necessary for a person’s physical or mental health.
Therapy and counseling are highly effective for substance abuse treatment and include behavioral therapies like cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT).
Wellmark covers most mental health and behavioral health therapies for policyholders, and also provides a service called Doctor on Demand, which gives access to mental health support virtually 24/7, including access to therapists.
Continuing care is the period of time after a person has completed addiction care, but during which they still need additional support as they transition back to their normal lives.
Addiction aftercare can encompass a wide variety of services, from relapse prevention support to a residential stay in a sober living home. It may be best to contact your Wellmark insurance agent directly to discuss what would be covered as medically necessary.
Under the Affordable Care Act (ACA), transitional living homes are not considered a formal treatment program, so Wellmark does not cover this type of continuing care treatment.
Wellmark BCBS Iowa offers a few different options for insurance coverage, and not all of these will provide equal coverage or complete coverage of drug rehab services.
Factors that can affect your Wellmark coverage for alcohol and drug rehab include:
Much of the information needed about your individual plan can be found within your coverage manual, and you can also contact us if you need help understanding your coverage.
Answer: Yes, Wellmark Blue Cross Blue Shield of Iowa does cover out-of-network provider costs for rehab programs or other medical services, but it depends on your individual plan.
Wellmark Blue HMO does not cover out-of-network medical services, with the exception of emergency situations, whereas Wellmark Blue POS does cover out-of-network services, which account for their highest out-of-pocket costs for members.
When signing up for a Wellmark BCBS health plan, people have a couple of options to choose from depending on their needs.
With Wellmark Blue HMO, as is typical with HMO insurances, members are given access to specific health care providers and hospitals, with out-of-network care not covered except for in the case of emergencies.
This insurance plan also covers preventative services, such as immunizations and screenings, for people at $0 cost when they utilize doctors or hospitals that are in-network.
POS insurance, which stands for point of service, allows policyholders to seek care from out-of-network providers in both emergencies or non-emergencies.
In situations where out-of-network non-emergency care is sought, Wellmark’s standard approval process requires authorization. Policyholders should expect additional out-of-pocket costs and higher premiums.
In terms of preventive care, services from out-of-network providers are subject to the same cost-share that in-network non-PCP specialists are subject to.
Substance abuse treatment generally falls under the category of mental health treatment, and covers a broad range of substance addictions.
Most of these are covered under Wellmark Insurance plans, however, not all treatment facilities offer all types of substance treatments.
Some of the addictions that may be covered by Wellmark Insurance include:
Contact us today if you are still unsure about whether your specific addiction or the treatment you are seeking is covered under your health insurance plan.
While Wellmark BCBS operates out of Des Moines, Iowa, there are health care providers throughout both Iowa and South Dakota which accept this type of insurance.
If you are a member of Wellmark BCBS who is seeking an office visit or treatment for a chemical dependency, it can be helpful to know how to find rehab centers in your area that accept this type of insurance.
One of your first steps can be to call the phone number on your Wellmark ID card and speak with a customer service representative for Wellmark, Inc. and Blue Cross and Blue Shield Association.
You can also use the search tool on the Wellmark members website, which allows you to search for providers or facilities that are in-network.
Finally, you can browse our list of rehab centers by state that includes information on the health insurance providers each facility accepts.
If you need more assistance in understanding your insurance coverage or would like help in locating a rehab center near you, contact RehabNet today.
We can help you locate facilities that accept Wellmark Blue Cross and Blue Shield as well as help connect you with a doctor who can provide prior authorization if needed.
We can also assist you with this information if you have a different type of private insurance or a state-funded insurance like Medicaid or Medicare.
To get in touch with one of our trained representatives, call our helpline or fill out our contact form at any time.
Healthcare.gov. “Health benefits & coverage.”
Healthcare.gov. “Mental health & substance abuse coverage.”
Wellmark. “Authorizations and Approvals.”
Wellmark. “Prescription Drugs and Pharmacy Benefits.”
Wellmark. “Virtual doctors and your mental health.”
Wellmark. “Wellmark Health Plan of Iowa.”
Wellmark. “What is a health insurance network?”
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