CareFirst, the not-for-profit healthcare company is an independent licensee of the Blue Cross and Blue Shield Association.
Plans include several core benefits, including prescription drugs, emergency care, hospitalization, preventive services, and treatment for behavioral health and substance use disorders.
Knowing that hospitalization and mental health care (including addiction) will be covered can be a source of comfort since many people worry about costs. Still, it’s good to understand that coverage can vary plan by plan.
Affordable Care Act
The Affordable Care Act (ACA) has put specific rules about health insurance coverage. All plans must cover some core essential benefits. These include doctor’s visits, prescription drugs, preventive care, hospitalization, emergency care, and lab work. It also includes mental health care and substance abuse services.
The law says that people can’t be denied coverage even if they’re ill or have a pre-existing condition.
Subsidies, or tax credits, can help keep premiums down. (Qualifying criteria shifts from year to year.)
The type of plan you have will determine where you can get treatment for addiction or mental health disorders. It’ll also determine your copays, deductibles, coinsurance, and permitted lengths of stay.
Costs will also hinge on the facility itself. Some centers offer more standard care, but others provide luxury rehab with sky’s-the-limit care and amenities.
CareFirst Levels of Care
All CareFirst plans comply with ACA rules. Plans will vary depending on where you live (Maryland, Washington, D.C., or Virginia), and that breaks down further depending on what metal level you want, as well as if you choose a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO) plan.
Metal levels of insurance coverage include bronze, silver, gold, and platinum.
- Bronze plans tend to have lower premiums but higher deductibles. With CareFirst plans, the insurance company pays 60% of the cost and you pay 40%. Often you’ll be responsible for meeting the deductible first.
- Silver plans cost a bit more from month to month, premium-wise, but out-of-pocket costs (including deductibles) tend to be a bit lower. The patient is responsible for 30% of the cost while the insurer covers 70%.
- Gold plans have higher monthly premiums but the insurance covers 80% of the cost.
- Platinum plans (available only in Washington, D.C.) cover 90% of the cost, and the patient is responsible for 10%. These have the highest monthly premiums.
There are some other options like catastrophic plans, usually best for younger patients with no health problems. They tend to have very low premiums but much higher deductibles.
HMOs only cover care that’s in-network, with the exception of emergency medical services.
PPOs are more flexible than HMOs. You’d be covered going out of network, but the costs will be slightly higher.
When shopping plans, it’s good to consider how often you might need to visit the doctor or a specialist, or if you may need surgery or other regular care. (Prescriptions are worth considering here, too.)
Drug and Alcohol Rehab
Does CareFirst cover drug and alcohol rehab? Plans do cover it, as it’s an essential service according to the ACA rulings. How much you’d be responsible for and where you can get treatment will depend on your plan. (CareFirst has information dedicated to answering questions about its behavioral health coverage.)
Substance abuse and behavioral health care can include emergency care, detoxification, inpatient treatment, varying levels of outpatient care, therapy, and more. What a patient gets will depend on their needs, what clinicians recommend, and often insurance approval.
If you have a bronze plan, you typically may need to pay the deductible first, which could range from $6,000 and up, and then insurance coverage will start. Hospitalization might be covered after the deductible is met. Some other charges may still apply.
Silvers would have a lower deductible (sometimes as low as half or even a quarter of a bronze plan’s deductible) and once that’s met hospitalization and related care would be 30%.
Gold plans have lower deductibles but patients would still need to pay a portion of the coinsurance, depending on the exact plan. Hospitalization might be a set daily amount until a copay maximum is reached.
Platinum plans cost the most in premiums but deductibles can be as low as zero dollars. Out-of-pocket maximums tend to be lowest, too.
For the 2022 calendar year, the out-of-pocket maximum for a Marketplace plan would be $8,700 tops for an individual.
Catastrophic plans will also cover addiction treatment but usually, it’ll be limited HMO coverage, with the highest possible deductible. There may be other limitations, too.
(Out-of-pocket limits do not include things like monthly premiums, services not covered by your plan, or out-of-network care. For those reasons it’s a good idea to check exactly what is covered and what the costs would be to avoid sticker shock.)
Length of Treatment
The length of treatment CareFirst insurance allows can vary.
The National Institute on Drug Abuse (NIDA) recommends looking at a patient’s health history, how long they’ve been using drugs or alcohol, for how long, and other factors like age, gender, and more as a treatment plan is devised. Usually a longer stay in rehab – three months is considered a solid minimum – makes for better results.
Rehab centers often work closely with insurance companies to get needed care approved (or added treatment days) for patients who find they may not be ready to check out of rehab just yet.
Does CareFirst also cover mental health? Mental health care is one of the ACA’s essential benefits, so CareFirst subscribers qualify for mental health coverage.
That can be extremely beneficial because mental health and substance use disorders frequently co-occur. When a person has both conditions, that’s a dual diagnosis. It’s important to treat both conditions since sometimes people will self-medicate with drugs and alcohol to dull the severity of disorders like depression or anxiety. Mental illness can also result from substance abuse.
Mental health care can take on the form of weekly counseling sessions, inpatient or outpatient treatment, or medications to manage symptoms.
CareFirst inpatient rehab is typically recommended for people undergoing drug or alcohol addiction treatment. A stay in inpatient rehab can last from 30 to 90 days, though some centers recommend people stay even longer, especially when severe drug or alcohol dependence is a factor.
Inpatient rehab takes place in several stages:
- Assessment. Here, the patient is examined by staff so they can get a complete health picture. That information helps mold a treatment plan for immediate issues and longer-term care.
- Detoxification. A lot of patients need to detox upon entering rehab. In this stage, they’ll get clean of drugs or alcohol. Some drugs, like opioids or benzodiazepines, can be difficult (and even dangerous) to quit cold turkey, so medical supervision ensures the patient stays safe. Medications may be administered to minimize withdrawal symptoms like nausea, vomiting, insomnia, and more.
- Treatment. This often includes behavioral or talk therapies like dialectical behavior or cognitive-behavioral therapy. The goal is to uncover what led to the addiction and learn healthier ways to cope with triggers and other stressors. Support groups are common in rehab, too. They can help patients realize they’re not alone in their struggles, and members can share advice.
- Aftercare. Here is where the patient is readied for life after rehab. They might be encouraged to check in regularly to report on progress or discuss victories and struggles. The patient usually is put in touch with support groups or counselors closer to home so they can continue their recovery beyond the rehab center. The goal here is to prevent relapse.
A longer stay in rehab allows patients to live substance-free for more extended periods and adjust more to that new reality. That can help yield better recovery outcomes. Inpatient rehab is a good way to distance oneself from outside distractions and temptations.
Before a person can enter inpatient rehab, prior authorization is usually required.
CareFirst outpatient services allow patients to try rehab without requiring them to stay at an inpatient facility. That can be helpful if they need the flexibility to go to work or handle family obligations. In these cases, the patient will follow a care plan that the center develops for them, and they may go to therapy several times a week, sometimes for several hours. After that, they might go home or to a sober living facility. The goal is to provide structure, but it also allows greater flexibility.
Suboxone is frequently used to treat opioid use disorder. The generic versions are a mix of buprenorphine and naloxone.
It is often part of a medication-assisted treatment program, a mix of behavioral (talk) therapies and medicine. Suboxone (or its generic equivalent) is safe to use long-term, and because it has a longer half-life and is less intense, that means the effects will not quickly wear off. That reduces the likelihood of someone scrambling to take more of some other opioid to keep withdrawal symptoms from setting in.
CareFirst does offer suboxone treatment, but it’s under the generic version of buprenorphine-naloxone.
Methadone is approved to treat opioid use disorders and can be part of a medication-assisted treatment program.
Methadone has a long half-life, reducing cravings and lowering withdrawal symptoms because it’s not as intense. That can keep someone in recovery feeling more like they’re on an even footing and less prone to relapse.
Does CareFirst insurance cover methadone treatment? Methadone is one of the approved drugs on CareFirst’s drug plans.
Paying for Rehab
Addiction rehab can turn pricey, especially if hospitalization, detox, and residential treatment are involved. Some people may think getting help for addiction is out of the picture due to that fear.
Insurance can help a lot. Knowing what your plan offers and sticking to in-network providers can keep costs down.
Deductibles and coinsurance are a given, so it’s good to find out the deductible, coinsurance, and copays as you look into rehab options. It’s also a smart idea to find out precisely what services are covered.
Insurance companies can answer a lot of questions. They’ll also be able to direct you to which rehab facilities would be in your network. They can also tell you what needs to be approved before rehab.
Addiction centers can offer a lot of answers, too.
Many rehabs can set up an installment plan for services not covered by CareFirst insurance policies to reduce costs, making it more manageable. In addition, some locations may offer financing options, too.
- individual.carefirst.com – Company Overview
- healthcare.gov – Mental health & substance abuse coverage
- individual.carefirst.com – Metal Levels
- individual.carefirst.com – Plan Types
- member.carefirst.com – Behavioral Health & Addiction
- healthcare.gov/glossary – Out-of-pocket maximum/limit
- nida.nih.gov – Principles of Effective Treatment
- sunshinebehavioralhealth.com – Co-Occurring Disorders & Addiction: Examining the Not So Hidden Links
- nida.nih.gov – Types of Treatment Programs
- sunshinebehavioralhealth.com – Cognitive-Behavioral Therapy for Substance Abuse
- samhsa.gov – Medication-Assisted Treatment (MAT)
Sunshine Behavioral Health strives to help people who are facing substance abuse, addiction, mental health disorders, or a combination of these conditions. It does this by providing compassionate care and evidence-based content that addresses health, treatment, and recovery.
Licensed medical professionals review material we publish on our site. The material is not a substitute for qualified medical diagnoses, treatment, or advice. It should not be used to replace the suggestions of your personal physician or other health care professionals.
Talk with one of our Treatment Specialists!
Call 24/7: 949-276-2886