Ambetter insurance is an Affordable Care Act (ACA) marketplace policy that currently serves millions of people across 20 states in the U.S.1 Like all ACA healthcare plans, Ambetter health insurance is required to cover mental health and addiction services.2 However, the level of coverage will vary depending on the Ambetter plan chosen and the state where the individual lives.
This page is intended to be a general overview of the type of coverage Ambetter healthcare provides, some health insurance basics, and ways to learn more about Ambetter health insurance plans.
Note: American Addiction Centers (AAC) endeavors to deliver the most current and accurate information on Ambetter addiction insurance coverage. However, policy changes and errors may occur. This page is merely an overview with some examples on how Ambetter insurance covers addiction treatment. It is not a comprehensive guide. Check with your insurance carrier directly or call 1-888-319-2606 Who Answers? to confirm your Ambetter coverage benefits.
Ambetter Coverage Levels and Ambetter Insurance Plans
Ambetter insurance plans are offered in 3 main tiers.2 Within each tier, there are different plans for different income levels and varying levels of coverage. These 3 main levels are:2
- Bronze: The bronze tier, or the Ambetter Essential Care package, provides healthcare with a low monthly premium (the amount a customer must pay each month to retain coverage). However, rates for services and emergencies with these plans will generally be higher than the two other levels.
- Silver: The second level, known as the Ambetter Balanced Care package, requires customers to pay higher monthly premiums. In return, Ambetter will pay a higher share of most medical bills.
- Gold: The final tier—Ambetter Secure Care—demands the highest premium, but the coverage provided in cases of emergency or necessary health services exceeds the previous levels.
It’s important to consider these options carefully when deciding on an insurance plan. While it can be tempting to choose a plan with the lowest possible monthly premium, there’s always the possibility this approach will cost much more in the long run should an emergency or the need for an expensive procedure arise.
Ambetter insurance provides coverage for residents in the following states:3 Arizona, Arkansa, Florida, Georgia, Illinois, Indiana, Kansas, Michigan, Mississippi, Missouri, New Hampshire, New Mexico, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Washington.
To compare pricing and coverage, visit the Healthcare.gov website to compare individual Ambetter plans as well as how they stack up to other health insurance providers, or visit the Ambetter website for detailed information on Ambetter-specific plans.
Does Ambetter Cover Inpatient Rehab?
Inpatient rehab and other substance use and mental health services are covered by Ambetter insurance.2 The out-of-pocket costs for these services will vary greatly depending on the specific plan chosen and the customer’s state of residency.
As an example, we’ll use the Ambetter Standard Silver Off Exchange Plan for an individual in Mississippi. This plan is available to individuals with an income that is 250% or higher above the poverty level.4
Here is a breakdown of the coverage provided by this plan if a patient chooses to receive treatment at an inpatient facility that is part of the Ambetter network:5
- The deductible—meaning the amount a customer would have to pay before insurance starts covering costs with this plan is $6,000.
- The out-of-pocket maximum for this plan is $8,500. This is the total amount the customer has to pay before insurance covers 100% of the rest of medical costs, with the exception of monthly premiums.
- There are no copayments that need to be paid for inpatient services with this particular plan.
- The co-insurance rate with this plan is 40%. This means that after reaching the $6,000 deductible, the patient is still responsible for paying 40% of the fees, until they reach the out-of-pocket maximum of $8,500. Since inpatient treatment tends to be fairly costly, this is the amount many individuals may expect to pay for inpatient rehab.
Drug or alcohol rehabilitation frequently employs the use of prescription medication. The costs of prescription drugs vary greatly depending on the type of drugs needed (e.g., brand name or generic, preferred or non-preferred brands, etc.) Costs can range from a $20 copay covering a 30 or 90-day supply to a 50% coinsurance rate.5
Note that the costs outlined above are for when an individual with this Ambetter health plan decides to opt for a treatment facility within the Ambetter network. With this plan, going outside the network will result in no coverage.5
Does Ambetter Cover Outpatient Rehabilitation?
Ambetter insurance also covers outpatient rehabilitation for drug and alcohol services.5 Using the same plan described in the above section, costs for outpatient treatment break down like this:5
- A $30 copayment for each office visit (deductible does not apply).
- 40% co-insurance rate for other outpatient services. In other words, Ambetter will play 60% of the costs until the out-of-pocket maximum is reached, after which they will pay 100% of the remainder.
Like with inpatient treatment, outpatient rehabilitation and aftercare may involve the use of prescription pills. The costs may range between a $20 copay and a 50% co-insurance rate.5
Once again, opting for treatment outside the Ambetter network results in no coverage.5
Does Ambetter Cover Mental Health Services?
Ambetter health insurance also covers mental and behavioral services.2 The inpatient and outpatient treatment costs outlined above are the same for mental and behavioral health patients as they are for people with substance use disorder (SUD).5
With any mental health, behavioral health, or drug and alcohol treatment service, it’s important to gain preauthorization with an Ambetter representative before enrolling in a facility.5
Checking Your Ambetter Insurance Benefits
To learn information specific to your Ambetter health insurance plan, you can:
- Login to your Ambetter account. If you have not already registered for online services, you may have to create an account.
- Call a customer service representative in your state to ask specific coverage questions.
- Look through the paperwork supplied by Ambetter when you enrolled in the healthcare plan.
If you are considering an American Addiction Centers’ facility and would like to learn more about how your insurance provider handles coverage, consider reaching out to an admissions navigator, use the “Verify Your Insurance” portal, or fill out the form below. Our admissions navigators are experts at guiding people through the confusing process of getting insurance to approve rehabilitation treatment.
- Ambetter. (2020). What is Ambetter?
- Ambetter. (2020). About our plan.
- Ambetter. (2020). Home.
- Ambetter. (2020). Plan brochures & benefits & coverage.
- Ambetter. (2020). Summary of benefits and coverage: what this plan covers and what you pay for covered services.
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