Marketplace plans (part of Centene)
Ambetter and treatment coverage
Ambetter plans are sold on the health insurance marketplace in many states. Most are HMO or EPO plans with a set network.
What Ambetter plans typically cover
| Level of care | Usually covered? | Usually needs approval first? |
|---|---|---|
| Medical detox | Yes, when medically necessary | Yes |
| Residential treatment | Often. Varies most by plan | Yes |
| Partial hospitalization (PHP) | Yes | Yes |
| Intensive outpatient (IOP) | Yes | Often |
| Outpatient therapy | Yes | Rarely |
| Medication treatment | Yes | Sometimes |
| Sober living | Rarely | n/a |
General guidance, not a statement of your benefits. Every plan is different. Cope or Die is not affiliated with Ambetter.
What to ask Ambetter
- Is this facility in-network for my plan? I am looking at group number ___.
- What is my deductible, and how much of it have I met this year?
- What is my coinsurance for inpatient and for outpatient behavioral health?
- What is my out-of-pocket maximum, and how much have I met?
- Do detox, residential, PHP and IOP need prior authorization? Who has to request it?
Common questions
Does Ambetter cover rehab?
Most Ambetter plans include benefits for substance use and mental health treatment, because federal parity law requires most plans to cover them on the same terms as medical care. What you pay depends on your specific plan, so have your benefits verified before you admit.
Does Ambetter cover detox and residential treatment?
Many plans do when the care is medically necessary, and most require prior authorization. Coverage for residential treatment varies the most from plan to plan.
How do I check my Ambetter benefits?
Call the member or behavioral health number on the back of your card and use the Cope or Die call script, or ask us to verify your benefits for you.
Not sure where to start?
Tell us what is going on. Someone who has been there will point you to the next right step. No pressure, no sales pitch.