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BCBS – Massachusetts

One of the first questions many people have when they’re considering substance abuse, mental health, or behavioral health treatment is whether or not their insurance company will entirely or partially cover the cost. Blue Cross Blue Shield (BCBS) is accepted in all 50 states and covers more than 100 million Americans. BCBS is made up of more than 35 independent and locally operated agencies, and more than 96 percent of hospitals and 92 percent of healthcare providers work directly with a BCBS agency. Blue Cross Blue Shield is accepted, at least on some level, by most addiction treatment centers, although coverage can vary widely from state to state.

The Mental Health Parity Act stops discrimination so that mental health treatment and substance abuse/addiction treatments are considered equal to treatment for medical health issues. In the past, insurers could place higher co-pay prices on mental health services and employers could limit the number of days their employees were hospitalized and/or attending outpatient services. These historical moves have made it much easier to obtain care. Lower prices and better cooperation within the workplace can help clients get the help they need sooner.

Oftentimes only a portion of detox, addiction treatment, or mental health treatment will be covered by your insurance. It’s important to speak with your insurance company to determine your exact level of coverage and to understand what that translates to in terms of the amount you will pay out of pocket.

Let’s get started with some common terms and definitions:

Copayment: a fixed dollar amount you are required to pay for covered services at the time you receive care.

Deductible: a fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins.

In-network: services provided by a physician or other health care provider with a contractual agreement with the insurance company and paid at a higher benefit level.

Out-of-network: services provided by doctors and hospitals who have not contracted with your health plan.

Out-of-pocket maximum: also called OOPM, this is the most you have to pay out of your own pocket for expenses under your insurance plan during the year. Deductibles, coinsurance, copays and other expenses for in-network essential health benefits (EHBs) apply to the OOPM.

Preauthorization: the process by which members or their primary care physicians (PCP) notify the health plan in advance of treatment plans, such as a hospital admission or a complex diagnostic test. Also called pre-notification.

Premium: the ongoing amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. The premium may not be the only amount you pay for insurance coverage. Typically, you will also have a copayment or deductible amount in addition to your premium.

BCBS offers different plans and levels of coverage, depending on your location. Common plans include bronze, silver, gold, or platinum level.  The Bronze Plan has the lowest level of coverage, the lowest monthly premiums, and the highest deductibles. Higher-level plans such as the Platinum or Gold have a higher premium but provide more comprehensive coverage and lower deductibles.

BCBS plans typically fall into two categories: an HMO (Health Maintenance Organization)  plan, or a PPO (Preferred Provider Organization) plan. An HMO plan gives its members access to certain doctors and facilities who have agreed to lower their rates for plan members. An HMO plan usually only covers doctors and facilities within their network. PPO plans have more options regarding the number of providers members can access.  With a PPO plan, covered individuals can be treated by a facility that is out-of-network, however, the expenses to the member will be considerably higher.

For mental health, behavioral health, and substance abuse services, coverage is usually as follows:

Outpatient services: $20/visit in network

Inpatient services: $500/admission in network

Out-of-network care is usually not covered and pre-authorization is required for certain services

A rough cost estimate for Inpatient Rehab with commonly used plans with BlueCross BlueShield:

Bronze Plan – Carry the minimum deductible amount for in-network providers.  Out-of-network Providers are usually NOT covered.

Silver Plan – Generally, a coinsurance % in addition to the deductible for in-network.  Usually, Out-of-network is NOT covered.

Gold Plan – Theses plans require a coinsurance % (usually this is a smaller amount than that of the lower level plans), as well as a deductible.  Out-of-network providers are not covered.

Platinum Plan –  Any In-Network provider services will have one or the other- a copay per day (with a maximum daily amount) or coinsurance percentage.  Sometimes Out-of-network services are covered.  If Out-of-network is covered, it will come with a higher coinsurance % as well as the deductible.

Every insurance plan is different, so the amount your insurer is willing to cover will vary depending on your provider. There may be a limit on how much is covered, and certain therapies may be excluded. We will verify your insurance at no cost, and are happy to discuss your payment needs with you.


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