Does Coventry Health (Aetna) Care Cover Rehab?

Serving individuals and groups, as well as Medicare and Medicaid recipients, Coventry Health Care offers a wide range of comprehensive healthcare coverage options. In May 2013, Coventry Health Care was acquired by Aetna, making it the third largest healthcare benefits company in the United States, serving over 22 million medical members across the country and around the globe.

Coventry Health Care provides behavioral health care services, which includes substance abuse services and mental health needs, through the MHNet behavioral healthcare company. Services provided through MHNet are confidential and may include:

  • Drug and/or alcohol abuse rehab
  • Preventative care
  • Inpatient services
  • Outpatient programs
  • Detox
  • Day programs
  • Acute and subacute programs
  • Mental health care
  • Medication management
  • Group therapy
  • Follow-up care

The National Survey on Drug Use and Health (NSUDH) estimates that over 21 million Americans who were at least 12 years old in 2014 suffered from a substance use disorder that year and could have therefore benefitted from rehab or substance abuse treatment of some kind. Health insurance is a great way to offset the costs of these services and make necessary treatment that much more accessible.

Types of Coventry Health Care Coverage

The level of care a person may be eligible for depends on their specific healthcare plan. Different states have variable rules and regulations regarding healthcare coverage. Plans may be provided through an employer, usually called group or commercial plans, through the federal government (Medicare and Medicaid), or they may be purchased by an individual.

Coventry Health Care plans offered to groups and employers provide access to the First Health Network, which is one of the largest Preferred Provider Organizations (PPOs) in the nation. A PPO provides a network of healthcare providers and services for individuals to use at a discounted rate. Individuals are able to go outside of the network and still file a claim for insurance coverage; however, the rates will be higher than when using a provider that is considered “in-network.” Providers that are in-network generally have an agreement with the insurance company to offer services for lower rates.

Individuals who are over the age of 65 qualify for Medicare, the federal health insurance program, which uses private insurance companies like Aetna and Coventry Health Care to provide coverage and services. Coventry Health Care provides Medicare Advantageplans to individuals in 19 different states and national First Health Part D prescription drug coverage.

Medicare Advantage plans cover healthcare services that are deemed medically necessary, and some may provide additional coverage, depending on the specific plan as well. Medicare Advantage Plans may cover both outpatient and inpatient substance abuse services when they are considered medically necessary and provided by an in-network provider.

Medicare plans may have up to four parts: Part A, B, C, and D. Medicare Part A is automatic and covers inpatient and hospital services, while Part B covers most other medical services, doctor visits, outpatient care, and other services, with the payment of monthly premiums, AARP explains. Medicare Advantage Plans are usually considered Medicare Part C, and this is what is covered by Coventry Health Care Medicare Advantage Plans after an individual is already covered with Parts A and B. These plans may be PPO, HMO (Health Maintenance Organizations), POS (Point of Service), or a combination of them. With an HMO, individuals are required to remain in-network for services to be covered. POS plans are usually a blend between an HMO and a PPO plan. Part D are prescription drug plans. Different states may have different Coventry Health Medicare Advantage Plans available.

Medicaid plans are offered to individuals with financial difficulties, and Coventry Medicaid managed health plans are available to those who qualify. The Coventry Managed Medical Assistance Program provides benefits free of charge to eligible individuals that include medically necessary services provided by in-network providers. Individual Coventry coverage is provided through CoventryONE plans that vary depending on the resident state.

Substance abuse services are considered to be “essential health benefits” under the Affordable Care Act (ACA), meaning that these services, along with mental health care services, must be covered in the same way that other medical or surgical procedures are covered.

Coventry offers individuals and small businesses (fewer than 50 employees) the option to buy coverage plans either through the federal Health Exchange Marketplace via a CoventryONE Health Insurance Exchange Plan or a CoventryONE Direct plan, which is purchased off the exchange. Both offer levels of coverage, ranging from bronze to silver to gold to catastrophic. Bronze CoventryONE Direct plans typically have the lowest monthly premiums (the amount paid to keep coverage current each month), cover services at 60 percent, and may have higher deductible (the amount of money that must be paid out of pocket before coverage kicks in) and copay (the set amount paid each visit at time of service) amounts. With the Silver CoventryONE Directplans, individuals pay 30 percent on covered services, while with the Gold CoventryONE Direct plans, 80 percent is covered and monthly premiums are higher.

Catastrophic plans are limited in their availability and eligibility. Typically, the person must be under 30 or have a demonstrated hardship. These plans have very low monthly payments but high out-of-pocket costs. They are meant to cover someone in the event of an emergency but are generally not for everyday medical needs.

Using a Coventry Health Care Plan for Rehab

In order to use a Coventry Health Care plan to pay for medical expenses, including rehab, individuals may first need a referral for services. Outpatient detox, intensive outpatient programs (IOP), residential, partial hospitalization (PHP), rehab, and inpatient acute care all require preauthorization through the MHNet behavioral healthcare portal.

Forms can be found in the Forms Library for those services that require it, although standard outpatient services do not require this step. For more information on behavioral health services and how to access them, Coventry Health Care members can login to the MHNet portal with their username and password. Individuals can also call the behavioral health services customer service number located on the back of the insurance card to talk to someone about their coverage.

Typically, an individual will first see their primary care provider to obtain a referral for rehab services. This helps the insurance company to realize that the services are deemed “medically necessary” and therefore covered by their insurance plan. Individuals may need to pay a copay for services. Then, the provider files a claim to the insurance company for payment, and any percentage not covered will be billed to the individual and needs to be paid out of pocket. In some cases, individuals may pay for services first and then seek reimbursement from the insurance company later.

Individuals may need to meet an annual deductible amount before coverage begins. Usually, plans also have a maximum out-of-pocket amount each year; after this amount is reached, eligible services are covered at 100 percent.

Rehab services may be covered only partially, depending on the specific plan. Individuals should read through their coverage specifics or talk to an insurance customer service representative for more information on what is covered and at what level. Substance abuse treatment providers usually have highly trained professionals on staff who can guide individuals and families through their insurance coverage and how to maximize a Coventry Health Care plan to pay for rehab and related services.

Verify Your Benefits Today

Learn more about how your insurance can work for you in addiction treatment by filling out the form below.