Ambetter insurance covers a host of medical and mental health needs, including the treatment of substance abuse disorder.1
Ambetter insurance covers over 2 million people across 20 states in the United States. A division of the Centene Corporation, Ambetter provides marketplace insurance plans as part of the Affordable Care Act (ACA).2
This page will give a brief overview of the addiction treatment coverage many Americans with Ambetter health insurance would expect to receive.
Please note: While American Addiction Centers (AAC) strives to provide you with the most updated information on each carriers’ addiction insurance coverage, policy changes and errors do occur. This is meant to be a brief overview of how Ambetter insurance covers addiction treatment and not a comprehensive guide. Please check with your insurance carrier directly or call 1-888-744-0069 to confirm coverage levels.
Ambetter Insurance Coverage Levels and Coverage Plans
Unlike many other healthcare companies, which offer employer-provided health insurance, Ambetter only offers ACA marketplace plans.1 These plans can be compared on the Healthcare.gov website, a similar state-run website, or the Ambetter insurance website. The following states offer Ambetter insurance coverage:3
- New Hampshire
- New Mexico
- North Carolina
- South Carolina
There are three different tiers of plans offered by Ambetter health insurance. These levels are:1
- Ambetter Essential Care (bronze): This offers low monthly premiums but relatively high out-of-pocket costs if a customer winds up needing serious care.
- Ambetter Balanced Care (silver). With this tier, Ambetter customers must pay slightly higher monthly premiums but will benefit from lower out-of-pocket costs should the need arise.
- Ambetter Secure Care (gold): requires the highest monthly premiums but covers the most in case of an emergency or expensive treatment.
Each plan covers mental health and addiction treatment; however, the out-of-pocket costs incurred may be very different. Before getting into specifics, there are some terms that should be defined for clarity:
- Deductible: The annual amount a customer must pay before Ambetter will begin covering expenses.4
- Copayment: Once a customer reaches their deductible, they’ll still have to pay a small amount for doctor visits or select other visits (e.g., $40 each time they see the physician).5 In some instances, their deductible may not apply to their copayment amount. This is often the case with prescribed medicine.
- Coinsurance: This is the percentage of the total cost a customer must pay when they need treatment. For example, if the coinsurance rate is 30%, Ambetter would cover the remaining 70% of the cost of treatment.6
- Out-of-pocket limit/maximum: This is the maximum amount a customer can spend per year (excluding monthly premiums). It includes deductibles, copayment, and coinsurance.7 Once a customer hits this amount, insurance covers the rest. Often, this will be the total amount owed for inpatient or outpatient treatment.
Does Ambetter Insurance Cover Inpatient Rehab?
Yes, Ambetter health plans cover inpatient drug and alcohol treatment, though the level of coverage provided will vary depending on the plan chosen. Inpatient rehabilitation requires preauthorization through Ambetter before undergoing treatment.8
Taking the standard cost share version of the 2019 Balanced Care plan for individuals that are 250% above the poverty level as an example, here’s a brief summary of coverage for inpatient care at a network provider facility:8
- The deductible of $6,500 (if it has not already been met).
- No coinsurance rate.
- No copayment.
If someone with this plan were to opt for a facility outside the Ambetter-approved network, Ambetter would cover none of the costs.8
NOTE: Prescription medication (sometimes a necessary part of rehabilitation treatment) will likely incur additional charges. In this particular plan, the charges would be between a $20 copayment (deductible would not apply) to a 20% coinsurance rate when using a network provider. Out-of-pocket costs largely depend on the brand of drugs (generic, preferred brand, or non-preferred brand).8
Using a provider outside the Ambetter network for prescription drugs would incur a 50% coinsurance cost.8
If Ambetter pre-authorizes you for coverage of these services with this plan, the maximum amount you can be charged is $6,800 for network-provided services and $1,300 for out-of-network services.
Does Ambetter Insurance Cover Outpatient Rehab?
Ambetter health benefits also extend to outpatient rehabilitation services. Outpatient rehabilitation requires pre-authorization through Ambetter before undergoing treatment.8 Using the same example plan used in the section above, costs for outpatient services at a network provider facility would look like this:8
- The deductible of $6,500 (if it has not already been met).
- No coinsurance rate.
- A $30 copayment each doctor visit (deductible does not apply).
Using a non-network provider for outpatient services would result in no Ambetter coverage.
Prescription medication may be required during and after outpatient treatment. In this particular plan, charges for prescription drugs range between a $20 copayment (deductible would not apply) to a 20% coinsurance rate when using a network provider. The out-of-pocket cost incurred from prescription medicine largely depends on the brand of drugs prescribed (generic, preferred brand, or non-preferred brand).8
Using a provider outside the Ambetter network for prescription drugs incurs a 50% coinsurance cost.8
If Ambetter pre-authorizes you for coverage of outpatient services or you require prescription medication, the maximum amount you’d be charged is $6,800 for network-provided services and $1,300 for out-of-network services according to this plan.8
Does Ambetter Cover Mental Health?
Other mental health problems are also covered by Ambetter insurance. In the summary of coverage, mental health services and substance use treatments are categorized together. The cost breakdown for inpatient or outpatient mental health treatment is the same as substance abuse treatment.8
Checking Your Insurance Benefits
There are several ways to check your Ambetter health insurance benefits. You can:
- Check your insurance paperwork that was supplied when you applied through the ACA marketplace.
- Call the customer service line specific to your state.
- Log into your Ambetter account. If you have not registered already, do so by providing your:
- Name and date of birth.
- Member ID number (located on your Ambetter ID card or on your monthly billing statement) or the last 4 digits of your social security number.
In most cases, Ambetter insurance provides coverage for addiction and mental health services, provided that you go through a network provider for treatment. Be sure to get your treatment pre-authorized by an Ambetter representative
Contact an admissions navigator to see if your insurance policy covers addiction treatment. Or, you can verify what your insurance covers by clicking here or filling out the form below.
Additional Resources on Health Insurance Providers and Coverage Levels
Visit the links below to find out more about your health insurance coverage levels, how to get your insurance company to pay for drug and alcohol rehab and also how to pay if you don’t have insurance.
- Blue Cross Blue Shield
- Kaiser Permanente
- Rehab insurance coverage
- Rehab without insurance
Additional Resources on Drug and Alcohol Rehab
Whether you’re looking for a specific type of rehab treatment, substance related info or additional guides, below are some our popular and recommended.
- Drug addiction hotline number
- Alcohol addiction hotline number
- Detox Centers Near Me
- Detoxing from Drugs at Home
- Free Drug Rehab Centers Near Me
- How to Help a Drug Addict
- State-Funded Rehab Centers Near me
- Ambetter. (2020). What is Ambetter?
- Ambetter. (2020). About our plan.
- Ambetter. (2020). Home.
- Healthcare.gov. (n.d.). Deductible.
- Healthcare.gov. (n.d.). Copayment.
- Healthcare.gov. (n.d.). Coinsurance.
- Healthcare.gov. (n.d.). Out-of-pocket maximum/limit.
- Ambetter. (2019). Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services.