Anthem, Inc. is one of the largest profit-oriented healthcare companies in the United States. Blue Cross and Blue Shield policies are offered in several states, including Nevada. Anthem is the primary provider for Blue Cross Blue Shield in the states where it operates. The company was founded in the 1940s as WellPoint, Inc.
At the current time, all insurance companies who participate in the Marketplace must abide by the policies passed in 2010 under the Affordable Care Act. Insurance companies must provide the same level of treatment for mental health services, including substance use disorder treatment, as they do for primary care services, such as surgery etc. This coverage extends to behavioral health treatments like psychotherapy, although certain types of psychotherapies and treatments that are not empirically validated may not be covered (e.g., the use of acupuncture in treating substance abuse, rapid detox, and certain types of psychotherapies that do not have empirical validation, such as past life regression).
Types of Policies
The type of coverage that one is subject to depends on the person’s specific plan. Anthem has several different plans that can be applied to substance use disorder treatment. These plans include four major categories, with variation within each level:
- The plans that are listed at the Bronze Level have the least expensive of all the monthly premiums but also will typically have the most out-of-pocket expenses. As a generality, these plans will cover about 60 percent of expenses incurred in treatment, but as with all the plans discussed in this article, there can be significant variation.
- The plans that are listed as Silver Level will have slightly reduced out-of-pocket expenses compared to Bronze Level plans but will also have higher monthly premiums. Generally, 70 percent of expenses are covered under these plans.
- Plans listed as Gold Level will have significantly lower out-of-pocket expenses but significantly higher premiums. They generally cover around 80 percent of expenses.
- Plans listed as Platinum Level will have the highest premiums but also the greatest extent of coverage and lowest out-of-pocket expenses. As an overall estimate, these plans will cover about 90 percent or a bit more of an individual’s costs. These plans may not be offered to individuals and may only be available for group plans.
Anthem provides both HMO plans (health maintenance organization, where an individual needs to use providers in a specific network in order to get coverage) and preferred provider organization plans (PPO, where an individual can choose a provider in or out of the network). PPO plans are typically more expensive.
According to information provided on its website, Anthem says that it provides coverage for a complete range of behavioral healthcare treatments that include the use of physicians, therapists, empirically validated treatments, and treatment in freestanding clinics or hospitals. One should expect that coverage for the treatment of substance use disorders will be dependent on several factors. This includes coverage for inpatient treatment services, withdrawal management or medical detox treatment, residential treatment, and other interventions, including therapy. These factors typically include:
- Medical necessity: If the treatment is deemed a medical necessity for the individual, it is covered. A referral for treatment from a physician, particularly an addiction medicine physician or psychiatrist, can satisfy this requirement for individuals attempting to get treatment for substance use disorders.
- Co-occurring disorders: If the person has a co-occurring diagnosis, such as depression, that also needs to be treated with their substance use disorder, this may complicate coverage.
- History: If the person has a past history of treatment and relapse, this can lead to complications with getting coverage and significant limitations on coverage.
- Legal issues: Any legal complications due to an individual’s substance abuse may complicate the extent of coverage.
- Type of substance: In some cases, the particular type of substance being abused may affect coverage.
- Expected length of the treatment: This is a particular concern when individuals are seeking residential or inpatient treatment. Often, coverage for psychotherapy (substance use disorder therapy) is limited to a specific number of sessions; then, the therapist must apply for more sessions in order to extend treatment. The company can decide whether to extend coverage for the sessions or not. If they are not covered, the person must pay the full cost out of pocket.
As always, it is suggested that individuals contact their insurance company’s customer service department and discuss the benefits that will be covered under their plan and any copays they must be prepared to pay given their individual circumstances. In addition, it is important to check with the particular treatment provider prior to getting treatment in order to determine if the provider accepts the insurance plan and what amounts the policyholder will be responsible to cover.