Will Insurance Cover an Addiction Caused Hospital Trip?

Addiction to legal substances (such as opioid prescriptions or alcohol) can cause overdoses and serious medical complications just as illegal substances (such as heroin). The symptoms of an overdose may range from vomiting to loss of breath, coma, liver failure and death, so you should seek medical attention as soon as you recognize such emergencies. Many people who are overdosing recognize that they are in need of medical attention, but some of them are reluctant to visit a hospital for help; they fear that they will be hit with high charges that may not be covered by their insurance plans, so they choose instead to face overdose on their own. This choice could cost them their lives.

In the event of a drug overdose or loss of breathing (a common result of opioid misuse), it is critical to get medical attention regardless of one’s insurance status. Hospitals are required by law to give medical attention to anyone who walks through the doors: no one can be denied medical treatment, and everyone is encouraged to seek help when they have legitimate needs for it. That said, will insurance cover the costs for addiction-related complications?

Growing Insurance Care for Addiction

The Affordable Care Act, which went into full effect in 2014, requires essential health benefits to be included in the coverage that insurance companies provide to citizens. These benefits cover all needed costs related to treating overdose. Of the 10 essential benefits required, the Act includes emergency services, hospitalization, mental health treatment, substance abuse counseling and behavioral health treatment that can include therapy and counseling. Mental healthcare professionals may be enlisted after hospital treatment, and the hospitalization may include added resources, such as ambulance services. The extent to which these costs are covered by insurance plans vary according to individual insurance plans, but some coverage always exists for these services1.

Insurance companies also cover charges related to getting prescription drug, but doctors have recently seen that prescription methods of treatment need to change. Patients who receive opioid prescriptions for pain are increasingly becoming addicted and unintentionally suffering from overdose complications due to other forms of drug poisoning. Sometimes, the anxiety that results from medication use leads to symptoms of mental health conditions, which are often covered by insurance, but not always.

According to the Drug Abuse Warning Network (a branch of the Substance Abuse and Mental Health Services Administration in the US Department of Health), almost 50% of hospital visits that involve drug issues result from reactions to prescription drugs. Furthermore, an estimated 45% of those visits involve drug abuse, most commonly with drugs such as oxycodone, hydrocodone and other opiates. In other words, half of all hospital visits that involve drugs stem from legal substances, and half of those cases involve people who abused these legal substances on purpose. This fact comes as no surprise, as an estimated 2 million Americans are addicted to opiates2.

Doctors are learning more and more about the addictive properties of opiates, so medical institutions are generally eager to help people who need help to clean up their addictions. When someone walks through a hospital’s doors and admits that he is there due to addiction, the medical staff will not be surprised and want to help. Furthermore, they know that overdose is often accidental: some people see the act of taking a drug or drinking as deliberate, but emergency treatment is necessary and covered by insurance. In short, you should deal with addiction-related emergencies by seeking medical help.

A hospital visit may increase premiums on an insurance plan. The 2012 Kaiser Family Foundation and Health Research program report that the average co-pay for emergency room admission was $188, and hospitalization after stabilization averaged at $2633. When insurance coverage is unavailable, other payment options usually exist, which can be arranged through the hospital to pay off bills a little at a time. Charities may also be willing to help, and the hospital’s billing department can help patients see if they meet the requirements for such donations. Lastly, a state or county program may help, along with the department of health4. In short, seek help as soon as possible not only to address drug abuse, but also to pay for it.

Help for Addiction Concerns

Health insurance concerns should never stop you from saving your own life. Besides, if your insurance company rejects coverage, then you can always appeal that decision. More information about your personal insurance plan (including how to file a claim and coverage details) are often available in each plan’s guide of benefits. You can also speak with an insurance specialist to find out how much coverage you are eligible to receive.

However, our toll-free helpline is available 24 hours a day. Our admissions coordinators can call your insurance provider to answer specific questions regarding drug-related questions. Call us today, and let us sort through your thoughts regarding prescription drug use, alcohol and addiction. We can help if you reach out now.


1 http://www.samhsa.gov/data/DAWN.aspx  Substance Abuse Mental Health Services Administration, Drug Abuse Warning Network Report, Published 12/10/15, Found 12/11/15

2 http://www.oas.samhsa.gov/2k10/DAWN034/EDHighlights.htm  Substance Abuse Mental Health Services Administration, Findings on Drug Related Emergency Visits, Published 12/28/10, Found 12/11/15

3 http://share.kaiserpermanente.org/article/kaiser-permanente-targets-reduction-of-opioid-prescribing/ Kaiser Permanente Targets Reduction of Opioid prescribing, Published 4/1/15, Found 12/11/15

4 https://www.usa.gov/help-with-bills#item-36707. Found 12/11/15