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Drug And Alcohol Rehabs That Accept UPMC Health Plan

Isaac Alexis, M.D., AAMA, AMP-BC

Medically reviewed by

Isaac Alexis, M.D., AAMA, AMP-BC

January 23, 2019

If you or a loved one are in need of substance abuse treatment and have a UPMC Health Plan, it is important to realize that you have coverage which can help you with your treatment needs. Attending a drug or alcohol treatment program can be the difference between continued substance abuse and ongoing sobriety.

About UPMC Health Plan

Based out of Pittsburg, Pennsylvania, UPMC Health Plan is owned by The University of Pittsburgh Medical Center (UPMC). UPMC serves over 3.1 million members. Their local provider network has numerous locations in Pennsylvania and also Maryland, Ohio, and West Virginia. This includes over 11,500 physicians and 125 hospitals who provide care for those who have individual, family, or employer-based plans.

Does UPMC Cover Substance Abuse Treatment?

There are three types of UPMC Advantage plans for individuals and families:

  • Health maintenance organization (HMO): Members have a primary care physician who must refer them to other providers, unless otherwise noted (as is many times typical with substance abuse). Typically, you can only see providers within your network.
  • Preferred provider organization (PPO): Within these plans you don’t need a primary care physician or a referral, either in-network or out-of-network; however, out-of-network costs may be higher.
  • Exclusive provider organization (EPO): These plans are a combination of the prior two. Like a PPO you don’t need a primary care physician or referral; however, the participating network of providers is smaller and you can’t typically seek services out-of-network.

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Here is an example of coverage for UPMC Advantage HMO, PPO, and EPO policies as taken from sample policies on the UPMC website. Your exact policy details may vary.

Services must be Medically Necessary and be provided by a hospital or provider who participates with UPMC and includes:

  • Inpatient and non-hospital detox
  • Inpatient and non-hospital residential rehab therapy
    • Room and board
    • Services of certified addictions counselors, nurse, physician, and psychologist
    • Diagnostic x-ray
    • Laboratory testing (medical, psychiatric, and psychological)
    • Medications
    • Use of equipment and supplies
  • Outpatient rehab
    • Individual and group counseling and psychotherapy
    • Psychiatric and psychological assessments
    • Family counseling for substance abuse

Prior authorization or pre-certification may apply for certain services and exclusions to treatment may apply to certain plans. For instance, the aforementioned sample policies write: “Any psychotherapy, psychiatric care, or treatment services for mental health or substance use that are court-ordered, unless such services are Medically Necessary… Methadone maintenance for the treatment of chemical dependency.”

Beyond their insurance coverage, UPMC’s Consumer Advantage offers several types of spending accounts which may also be utilized to pay for drug addiction treatment, including:

  • Flexible Spending Account (FSA)
  • Health Reimbursement Arrangement (HRA)
  • Health Savings Account (HSA)

Contact a UPMC representative for a full explanation of your substance abuse treatment benefits.

Does UPMC Offer Medicare or Medicaid Services?

Medicaid is a combined federal and state initiative which, with the Children’s Health Insurance Program (CHIP), offers health coverage to low income individuals or families and “children, pregnant women, parents, seniors, and individuals with disabilities.”

Medicare coverage is for those individuals who are 65 years of age or older, though other factors may apply. The Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) notes that “While there is no distinct Medicare benefit category for substance abuse treatment, such services are covered by Medicare when reasonable and necessary.” Medicare services include:

Medicare Part A and B

Your regular UPMC insurance may work in conjunction with Medicare Part A and B. These plans may supplement your existing coverage by helping to pay for addiction treatment, including inpatient or outpatient treatment or partial hospitalization. Certain medications may be bundled within these types of coverage.

Medicare Advantage Plans Part C

Beyond these plans, UPMC offers Medicare Advantage plans, which are private, Medicare-approved health plans called UPMC for Life plans. According to UPMC, these plans are different in the capacity that “They allow you to get all your Part A Hospital, Part B Medical, and sometimes, Part D Prescription Drug coverage combined into one plan.” These plans may offer the combined substance abuse treatment benefits of the individual Medicare components.

Medicare Part D

This is a form of Medicare prescription drug coverage which is offered through private insurance companies such as UPMC. UPMC offers several plans that combine this with medical coverage. This coverage may cover certain prescribed medications; for instance, the CMS lists Suboxone, a medication used for opioid dependence, as an example.

In addition, UPMC also offers UPMC for Kids (a CHIP program for uninsured children and teens); UPMC for You, a Medical Assistance (Medicaid) plan; and UPMC for Life Dual which is for those individuals who qualify for both Medicare and Medicaid. In order to determine the exact extent of coverage which may apply to substance abuse treatment or medications, you should contact Medicare, Medicaid, or UPMC.

UPMC Supports A Person’s Behavioral Health Needs

Many individuals commonly face a mental health disorder alongside of an addiction; this is called a co-occurring disorder. In addition to insurance coverage, UPMC offers several resources which support you or a loved one in these concerns before, during, or after you’ve received treatment, including:

Beating the Blues US—is a free member service which draws upon ten years of research. It helps members deal with stress or other concerns within their life.

LifeSolutions—this support service is free to certain members and includes “24/7 support and online access to articles, links, interactive content, and self-assessments that can help you with work-life balance.”

Behavioral Health Management Programs—help members to become educated on and utilize resources for their mental health concerns.

Paired with other methods of aftercare support and service, these tools may help UPMC members better maintain their recovery.

What Questions Should I Ask About My Coverage?

It can be intimidating to try to make sense of your insurance. Fortunately, you don’t have to wade through all the fine print and technical terms yourself. UPMC offers their members support through their Health Care Concierges—highly-trained staff who are standing by for this very reason. These individuals can break down the components of your coverage and explain in-depth information concerning your deductible, out-of-pocket expenses, copays, and coinsurance.

To help you, we’ve assembled a list of questions that you can ask, such as:

  • Is drug and alcohol rehab detoxification covered by my plan? Is rehab? Are both together?
  • Is the covered amount partial or full coverage?
  • If I prefer treatment which is not in-network, do I receive any coverage at out-of-network facilities? If so, what?
  • Do you have a list of in-network facilities who accept this insurance?
  • If inpatient treatment is necessary, is there a maximum length of stay or daily limit you cover?
  • Once treatment begins, are there certain services you do and do not cover?
  • Will my plan cover the appropriate medications, if necessary?
  • Are any type of aftercare services included?

In addition, once you’ve made a list of facilities you are interested in, you can also speak to the facilities directly. Asking these questions should help you to better understand your coverage. This combined knowledge can help to make your treatment needs a reality.

What If I Need More Assistance?

Insurance is not your only option. Beyond this, you may be able to find additional resources through scholarships or grants, certain types of loans, medical credit cards, and/or contributions or loans from family or friends. Other options may exist from the facility directly—some rehabs offer reduced or sliding fees, or they may work with an outside company to offer you financing options.

We Can Help You Put Your Insurance To The Best Use

Facing addiction alone is overwhelming. Our trained staff at RehabCenter.net can help you to connect you with the best rehab centers that accept UPMC Health Plan. Whether you’re curious about your financial options or interested to learn more about what treatment programs may be best for you, we’re here to help. Contact us now.

UPMC Health Plan - UPMC Health Plan

Centers for Medicare & Medicaid Service - The Mental Health Parity and Addiction Equity Act (MHPAEA)

The Department of Health and Human Services’ Centers for Medicare & Medicaid Services - Medicare Coverage of Substance Abuse Services

Medicaid.gov - Eligibility

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