Does MassHealth Insurance Cover Alcohol and Drug Rehab?
Treatment for alcohol and drug abuse, as well as mental health disorders, belongs to the category of essential health benefits. Therefore, it’s covered by all commercial, state-regulated medical insurance providers, including MassHealth.1
Historically, SUD treatment was rarely covered (or not covered at all) under private and public insurance plans. Even when some of it was covered, treatment was seriously limited by high copayments, annual limits to the number of visits, and placing the required medication on higher tiers. This was the main reason many Americans couldn’t access affordable SUD treatment, and why most still consider alcohol and addiction treatment to be cost-prohibitive.2
The Affordable Care Act of 2010 was a response to the US opioid epidemic. It requires all state-regulated insurance providers to offer the same level of benefits for mental health and substance abuse disorders as they do for medical or surgical services. Therefore, MassHealth insurance covers the cost of the full range of medically necessary addiction treatment services.2
However, only part of your treatment might get covered, depending on your health plan and the type of treatment. Based on the individual needs of each patient and the type of insurance plan they have, covered SUD treatment may include drug detox, outpatient and intensive outpatient treatment, residential or inpatient treatment, pharmacotherapy, and aftercare (or recovery support) services. These services are provided together with various forms of psychosocial treatment.2
How to Check MassHealth Insurance Coverage for Addiction Treatment
MassHealth may cover all or part of your addiction treatment cost. To find out if the treatment you need can be covered by MassHealth insurance benefits, you can reach out to the rehab centers you’re interested in and provide your insurance information so they can check your coverage. You can also contact MassHealth by calling the number on the back of your insurance card, and ask about the details of your insurance coverage.
MassHealth offers coverage for substance abuse and mental health disorder services through Massachusetts Behavioral Health Partnership (MBHP). MBHP may cover a wide range of services, including:3
- Visits to therapists, social workers, psychologists, and psychiatrists.
- Emergency services and crisis counseling.
- Detoxification services and SUD treatment.
As one of the in-network substance abuse providers that collaborate with MassHealth, American Addiction Centers (AAC) can also verify your benefits and check if your treatment would be covered by MassHealth. You can perform this check by filling out and submitting an online verification of benefits form on the AAC website. Enter your health insurance information to immediately find out whether your health insurance provider is in-network with ACC and if it will provide MassHealth rehabilitation coverage.
Another option is calling the AAC helpline and speaking to one of the admission navigators who can check your benefits during the call if you have your insurance card with you. They can also guide you through the intake process and the initial steps of assessment by a team of addiction specialists.
If you’re unsure about the severity of your issues and need general information about addiction and high-quality rehab centers, there are free, 24-hour addiction hotlines you can call and talk about anything that’s on your mind. Trained addiction advisors can suggest the next steps and direct you to the most appropriate rehab facilities based on your needs.4 The confidentiality of any personal and medical information you choose to share is protected by law.5
What Is MassHealth?
MassHealth is a health insurance provider that operates in the Commonwealth of Massachusetts. This program was established as a combination of Medicaid and the Children’s Health Insurance Program (CHIP) to provide health care to low or medium-income patients and families, seniors, and other vulnerable uninsured population groups living in Massachusetts.3
As a public, state-run program, MassHealth either provides health benefits directly to those who qualify, or it covers the cost of their medical insurance premiums, completely or partially. MassHealth members have access to doctor’s visits, hospital stays, prescription drugs, and other medical services.6
MassHealth members are also provided with coverage for behavioral health services. This means that they can get insurance coverage for addiction treatment and mental health disorders.7
What Are MassHealth Coverage Levels and Plans?
To receive the necessary benefits, a patient must be a MassHealth member. This means applying for MassHealth coverage first, and then MassHealth will determine which program or coverage type each patient can get. Patients will receive the most complete coverage for which they are eligible.8
The eligibility is based on income, age, citizenship, and some other special circumstances. Being a Massachusetts resident is a requirement for getting access to any of the MassHealth services. Some patients may have to add copayments for some of the services. To determine eligibility, patients need to meet some financial requirements, like income and household size.
Eligible Massachusetts residents are offered six MassHealth coverage types:9
- Family Assistance.
- Premium Assistance.
Available MassHealth Plan Options
To become eligible for managed care, you must be approved for MassHealth coverage. Then you can enroll in one of the health plans offered in your area. These are the available options:10
- Accountable Care Partnership Plan
- Primary Care ACO Plans
- Managed Care Organization Plans
- Primary Care Clinician (PCC) Plan
The specifics and coverage of each plan vary. MassHealth members have access to different networks of healthcare providers depending on the plan. Members are attributed to groups of primary care providers, and each plan’s “referral circle” provides access to other providers or specialists without the need for a referral from your primary care provider.11
MassHealth members can use the Massachusetts Behavioral Health Partnership (MBHP) network of hospitals and specialists for behavioral health services.12
Which States Do MassHealth Operate In?
MassHealth operates in the Commonwealth of Massachusetts as a brand of Medicaid. Members have access to local SUD and mental health services through the Massachusetts Behavioral Health Partnership (MBHP). Since Massachusetts is the most populous state in the New England region, the MassHealth network of more than 1,200 providers manages behavioral healthcare services for more than 500,000 members across the state, from Boston to other major cities like Worcester, Springfield, and Cambridge.6
What Will MassHealth Insurance Cover?
All MassHealth plans cover visits to a primary care physician’s office, lab tests, and prescription medication. They also include mental health and addiction services, including inpatient and outpatient treatment in clinics and hospitals.13
Certain services may require preauthorization or a referral from primary care physicians. Some plans, aside from the above-listed basic benefits, offer some additional benefits. Those will be different for each plan.13
MassHealth insurance will cover services that are determined to be appropriate and medically necessary according to MBHP medical necessity criteria. These are guidelines for the appropriate level of care for MBHP members. The criteria are designed to achieve stabilization and recovery from the symptoms of mental illness and/or SUDs. They determine the clinical necessity and appropriate level of care for individuals who receive services through MBHP programs.14
Treatment Elements Covered by Insurance
Depending on the plan you have, MassHealth may provide coverage for some or all the costs of the substance abuse treatment program:15, 16, 17
- Inpatient/residential rehab is the type of program that requires the struggling individual to live at the rehab facility for the duration of the treatment. Inpatient treatment programs can be short-term or long-term.
- Short-term programs usually involve up to a week of medically monitored detoxification, with or without pharmacotherapy (use of medications to ease the symptoms of withdrawal), and they usually last for 28-30 days.
- Long-term programs are recommended for individuals with severe addiction and last for 60 days, or even 90 days if determined necessary. In most severe cases, particularly ones accompanied by mental health issues, they may last up to a year.
- Outpatient rehab is the type of addiction therapy that requires regular visits to the rehab center but the patient lives at home. During those visits, patients attend therapy sessions, just like in inpatient programs. Cognitive-behavioral therapy and motivational interviewing are the most common and most effective types of psychotherapy.
- Intensive outpatient programs (IOP) are a more intensive type of outpatient therapy that usually involves more hours spent at the rehab center. Aside from individual counseling, patients may take part in a group, family, or marital counseling.
- Partial hospitalization programs (PHP) include elements of both outpatient and inpatient treatment. The patient does not live at the facility, but they do spend a minimum of 20 hours there per week. They usually last for a couple of months.18
Does MassHealth Insurance Cover Mental Health Care?
Mental health issues often co-occur with substance abuse disorders. About half of people with a substance use disorder also experience various degrees of mental health issues, even serious mental illness. It’s hard to determine whether mental health problems are the underlying cause that leads to addiction, or if they develop because of it.19
Either way, treating one and disregarding the other might lead to relapse and failed addiction treatment. That’s why effective approaches to treating substance abuse require that both conditions be addressed simultaneously.19
MassHealth provides outpatient mental health services through MBHP. Its wide network of providers enables quality care access to MassHealth members in various settings like hospital outpatient departments or clinics and community health centers. Mental health treatment may include individual and/or group therapy, as well as therapy for couples and family therapy. These therapy sessions help patients deal with issues like anxiety, depression, or trauma.20
MassHealth integrates various levels and systems of care to provide:20, 21
- Continuity between inpatient and outpatient treatment.
- Evaluation and dual diagnosis for co-occurring mental health issues and SUDs.
- Addressing and treating comorbid physical and behavioral health conditions.
- Treatment for mental health issues and SUDs in a general medical setting.
What Treatment Durations Does MassHealth Insurance Cover?
The length of substance abuse treatment that will be covered by MassHealth insurance will depend on what a team of specialists determines to be medically appropriate and necessary for your case. It will also depend on the type of insurance plan you have since there are different policies and tiers of coverage.22
Longer treatment times are considered to be more effective and there are indications that they raise the chances of achieving long-term sobriety and result in fewer cases of relapse. However, since all treatment programs are designed to fit each patient’s needs, life circumstances, belief systems, and background, some of them might include approaches or elements that are not considered medically necessary, even if their benefit to a particular individual might be significant.17
In these cases, patients can explore other payment options to complement the amount covered by MassHealth insurance. To find out what kind of coverage your plan provides, look up the information in your contract or reach out to a MassHealth hotline. Their representatives can explain everything you need to know about your options and help you make the best decision and receive the maximum coverage for treatment.23
What if My MassHealth Policy Does Not Cover Rehab?
Depending on the treatment center you choose, the type of treatment you need, and the insurance plan you have, you might not get full coverage for the kind of treatment that would be most effective in your case. If this happens, you can look into alternative financing options. Some rehab centers offer free or low-cost care and sliding-scale fees, while some treatment facilities offer grants or scholarships.24
Your eligibility for some services depends on your annual income and household size. These factors also determine whether your whole treatment will be covered or just part of it. Additionally, the funding can be revoked if you don’t complete the program.24
Cash or self-payment is accepted in 90% of all rehab facilities, while the sliding fee scale option was reported by 59% of facilities. Completely free treatment at no charge, for those without the financial means to pay for rehab, is available in 44% of all facilities.25
The price of substance abuse treatment is often viewed as cost-prohibitive, and the number of people that need treatment but never get it is alarming. The cost of untreated addiction is a lot more expensive for both the individual and society. Active addiction leads to loss of income, due to diminished productivity, as well as substance abuse-related legal problems.26
MassHealth In-Network vs. Out-of-Network Rehab Centers
If you’re a MassHealth member and are enrolled in a private health plan through this program, the easiest way to find out which behavioral health and SUD treatment providers are ‘in-network,’ meaning they participate in the type of health plan you have, is to call the customer service department of your insurer.
In case you’re not enrolled in a health plan, you can go to any provider that is in-network with the Massachusetts Behavioral Health Partnership. The MBHP network is one of the largest providers in Massachusetts. It includes over 1,200 facilities, individual practitioners, and inpatient programs.5
You can check the MassHealth Provider Directory for addiction treatment and mental health providers list, as well as primary care providers, specialists, and hospitals. There is also an Integrated Care Management Program (ICMP) which offers enhanced care for more complex mental health issues and/or SUDs. Available services include detox, crisis counseling, and long-term therapy.27
You don’t need a referral for MBHP in-network providers. If you use an in-network provider’s services for behavioral health care, there is no co-pay and it’s your provider’s responsibility to obtain authorization for services.3
If you don’t know which plan you have, or what your in-network providers are, you can call the MassHealth Customer Service Center at 1-800-841-2900.