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There’s a rising pattern in substance use in Phoenix. From alcohol to marijuana to opioids, this pattern has led to addiction and deaths. This calls for effective drug rehab services to help individuals struggling with substance use disorder (SUD) or opioid use disorder (OUD).

Aetna is a leading insurer with a range of addiction treatment coverage options. It has millions of medical members with access to over 600,000 providers and more than 5,000 facilities. Aetna’s plans allow for individualized treatment planning, including negotiated in-network rates and coverage tailored to your needs.

This article will explain what Aetna covers in Phoenix. You’ll understand the types of treatment available and how to use benefits effectively. If you or your loved ones need help with insurance or getting drug rehab treatment, please reach out to our team at Nirvana Recovery. We’re a trusted partner for navigating insurance and treatment options.

Types of Drug Rehab Covered by Aetna in Phoenix

Inpatient and Residential Treatment

Aetna includes the following in inpatient/residential treatment as part of its behavioral health benefits:

Substance use disorder treatment
Therapy and continuing care
Medically supervised detox
Inpatient/residential rehab

Many plans cover inpatient stays of 30 to 90 days, depending on the plan’s specifics and the level of clinical need. Aetna requires ongoing assessments of your progress and clinical needs to justify continued inpatient care. They reevaluate their decisions at regular intervals.

Aetna needs pre-authorization for inpatient/residential treatment to confirm medical necessity.

Outpatient and Intensive Outpatient Programs (IOP)

Standard outpatient treatment involves individual therapy, group sessions, or counseling. Frequency can vary, but expect weekly sessions or scheduling as needed. Costs depend on your specific Aetna plan’s deductibles, copays, and coinsurance. Aetna covers standard outpatient care under its behavioral health benefits.

An intensive outpatient program (IOP) involves a structured program of 9 to 19 hours per week. Sessions are scheduled in the mornings or evenings to avoid disruption of your daily routine. The higher frequency and structured nature mean higher costs. Aetna covers IOP under the American Society of Addiction Medicine (ASAM) Level 2 services.

Partial Hospitalization Programs (PHPs)

A partial hospitalization program (PHP) offers intensive, therapy-driven treatment during the day. You attend 5-8-hour sessions per day for 5 to 7 days per week. Sessions include individual therapy, group counseling, psychoeducation, medication support, and skill-building. You return home in the evening.

PHP is an ideal option for people stepping down from inpatient treatment or for those who need more structure than outpatient care provides. Aetna covers PHP in many of its plans when medically necessary. Aetna may require prior authorization to ensure treatment is clinically justified.

Medication-Assisted Treatment (MAT)

Aetna covers the following medicines used in medication-assisted treatment:

Buprenorphine and Suboxone (Buprenorphine + Naloxone): No prior authorization is required for suboxone for most employer-based commercial plans
Methadone: Coverage is provided through the medical benefit. Methadone must be dispensed through a licensed opioid treatment program (OTP)
Naltrexone: Coverage is under the medical benefit. Providers are allowed to administer extended-release naltrexone

MAT is usually combined with counseling services for better treatment outcomes. However, therapy isn’t strictly required for approval.

Counseling and Therapy

Aetna includes individual, group, and family therapy within its behavioral health and substance use disorder benefits. Coverage for these therapies depends on your plan.

Individual therapy sessions are carried out one-on-one with licensed therapists. They may happen in-person or through telehealth.

Group therapy offers you the opportunity to engage with peers, share experiences, and learn together or from each other under professional guidance.

Family therapy involves family members in the treatment process. This fosters better communication, understanding, and long-term support.

Aftercare and Relapse Prevention

Many Aetna plans cover aftercare support programs, which may include the following:

Ongoing outpatient therapy (individual, group, or family)
Skill-building and relapse prevention workshops
Peer support group meetings or gatherings

Aetna may require pre-authorization for structured programs like inpatient treatment, PHPs, and IOPs. But continuing care and outpatient aftercare therapies have fewer authorization requirements.

Aetna recognizes that long-term recovery isn’t a personal journey; it relies on community support. Continuing care and relapse prevention also support sustained sobriety.

Aetna Plan Types in Phoenix and How They Affect Coverage

HMO Plans

Aetna Health Maintenance Organization (HMO) plans cover only in-network services, except in emergencies. You should use providers that are part of Aetna’s network to enjoy full coverage. These plans require you to select a primary care provider (PCP) who manages your care and handles referrals to specialists. HMOs also require you to get a referral from your PCP to see a specialist, except for certain emergencies.

HMOs have lower premiums, deductibles, and predictable copays. They’re more cost-effective than Preferred Provider Organization (PPO) plans.

Aetna’s unique HMO plans include:

Aetna HMO Plan: Standard HMO requiring PCP selection and referrals; provides in-network coverage only
Aetna Health Network Only Plan: Network-based, but no PCP required; referrals are encouraged but aren’t required
Aetna Select (Open Access Plan): Allows visits to in-network providers without a referral; includes no deductible

PPO Plans

Aetna’s PPO plans allow you to see specialists or providers without needing a referral or a PCP. This gives you more autonomy than HMO plans. You can also receive care from in-network and out-of-network providers and facilities. However, going out of the network means higher costs and more paperwork.

Aetna PPO plans are ideal if you want the following:

Provider Flexibility: You don’t need to have a PCP or referral, and you can access both in-network and out-of-network providers
Convenience: Aetna processes in-network claims for you, and paperwork is minimal
Adaptability: They’re suitable for those with complex healthcare needs or who desire to keep their provider relationships intact, even if switching plans

EPO Plans

An Exclusive Provider Organization (EPO) plan offers a network of healthcare providers. Its coverage is provided only for services rendered by in-network providers, except in emergencies. Unlike PPOs, EPO plans do not cover out-of-network care. Depending on your specific EPO plan, you may or may not need a referral from a PCP to see a specialist.

Aetna EPO plans have the following benefits:

Lower Premiums: They’re cost-effective compared to PPO plans
No Referrals Needed: Some EPO plans, like the Aetna Open Access Elect Choice plan, do not require referrals to see specialists
Extensive Network: EPO plans have a large network of providers, ensuring access to a wide range of healthcare services
Simplified Billing: With in-network care, billing is straightforward

Aetna Medicare and Medicaid Plans

Medicare Advantage (Part C) plans combine the benefits of Original Medicare (Parts A and B). They may include additional benefits such as prescription drug coverage (Part D). Individuals with low income, special needs, or disabilities may qualify for Medicaid coverage. Medicaid plans cover hospital and doctor visits and prescription drugs. Coverage and benefits may vary by state.

Certain services and medications, such as MAT, require prior authorization with Medicare and Medicaid plans. Medicare Advantage plans may also have network restrictions; out-of-network services may not be covered except in emergencies. Medicaid coverage and rules can vary between states. Review the Evidence of Coverage (EOC) document for specific details.

How to Verify Your Aetna Benefits for Rehab in Phoenix

Review Your Summary of Benefits

Here’s how you can locate substance use disorder coverage information from your Summary of Benefits (SBC):

Get your SBC from Aetna’s website or your member portal.
Review the “Common Medical Event Services You May Need” section. It lists covered services and associated costs.
Look for “Behavioral Health” or “Substance Use Disorder” entries. Find services such as inpatient detox and rehab, outpatient counseling and therapy, and medication-assisted treatment.
Check for prior authorization requirements; note services that have them, such as MAT.
Review cost-sharing details, such as copayments, coinsurance, and deductibles for SUD-related services.

You can also review the Behavioral Health Precertification List. It outlines specific behavioral health services that require prior authorization, including many SUD treatments.

Call Aetna Member Services

Ask questions about the following:

In-Network Status

How can I verify a specific provider is in-network?
Are there any restrictions on out-of-network substance use disorder services?

Costs

What are the copayments, coinsurance, and deductibles for substance use disorder services?
Are there separate deductibles or out-of-pocket maximums for behavioral health services?

Session Limits

Are there limits on the number of therapy sessions covered for substance use disorder treatment?
Do these limits apply to individual, group, and family therapy sessions?

Pre-Authorization Needs

Which substance use disorder services require prior authorization?
What is the process for getting pre-authorization for substance use disorder services?
How far in advance should I request pre-authorization before starting treatment?

Use a Rehab Facility’s Verification Service

Confirming insurance on your own can be time-consuming or feel complicated. That’s why you have Nirvana Recovery. With your authorization, we can confirm Aetna coverage for you quickly. To get started, complete a secure online form on our website. We will require the following details:

Insurance provider (e.g., Aetna)
Member ID
Policyholder’s name and date of birth
Your basic information, including your email address and phone number
Information on who’s seeking treatment (if it’s not you)
Patient’s name and date of birth (if it’s not you)

Once you submit the above details, our admissions team reviews them and contacts Aetna directly. We will contact you as soon as we receive your coverage specifics from Aetna.

Understanding Pre-Authorization and Medical Necessity

Pre-authorization is the process by which Aetna evaluates the medical necessity of requested healthcare services before they’re provided. This step is essential in determining whether a service is covered under your plan and in ensuring it meets Aetna’s criteria for medical necessity.

Clinical records, treatment plans, and supporting documentation are required for prior authorization. Approval for standard requests takes up to two weeks. However, expedited reviews may get responses after 24 hours.

Medical necessity refers to healthcare services that are:

Clinically appropriate
Not primarily for the convenience of the patient, physician, or other healthcare provider
Not more costly than an alternative service that’s likely to produce equivalent diagnostic results

Aetna determines medical necessity based on generally accepted standards of medical practice and clinical guidelines.

Common Challenges With Aetna Rehab Coverage in Phoenix

Claim Denials

The following are common reasons for claim denials by Aetna:

Lack of medical necessity. The submitted documentation did not sufficiently demonstrate that the service was medically necessary.
Failure to get prior authorization. Aetna may deny a claim if this step is overlooked for services that require pre-authorization.
Using out-of-network providers. Aetna may deny a claim if your plan doesn’t cover out-of-network care.

You can appeal a denied claim. Here’s what you need to do:

Review the denial notice. Note the reason for the denial and any required documentation for the appeal.
Prepare all relevant documents to support your appeal.
Submit your appeal.

Coverage Limits and Caps

Here are different duration restrictions and session limits for different services:

Inpatient/Residential Treatment: Aetna determines length of stay based on clinical need, guided by the ASAM Criteria and MCG behavioral health guidelines
Partial Hospitalization Programs: Duration is based on clinical needs, similar to inpatient guidelines
Outpatient Therapy: Caps may range between 20 and 30 sessions per year, but actual coverage varies by plan

Review your Summary of Benefits and Coverage (SBC) for more information on annual limits on residential days or therapy sessions. Call Aetna Member Services. Ask about limits like “maximum inpatient rehab days per year” or “session caps for outpatient therapy.”

Out-of-Network Access Issues

Aetna may approve exceptions in the following cases:

When there’s a lack of in-network providers. In some cases, you may find that no in-network provider is qualified or available for your condition. For example, a specific type of psychiatrist or addiction specialist. You can thus request a network gap exception. This means that Aetna allows you to access out-of-network care at in-network rates.
When in-network providers are not accessible due to long wait times, geographic barriers, or scheduling issues. Aetna may consider allowing access to out-of-network care at in-network rates.
When there’s an emergency. Most plans automatically cover such situations.

Myths About Aetna Drug Rehab Coverage

“Aetna Doesn’t Cover Long-Term Rehab”

Aetna can approve extended rehab stays when they’re clinically justified. Most plans authorize an initial stay of around 30 days. They then require updated progress notes and reassessment to extend the stay.

Furthermore, coverage depends on necessity, not a time cap. Aetna’s clinical policies require that inpatient/residential treatment be medically necessary. They use standard clinical guidelines when deciding whether the duration of care is justified.

“MAT Isn’t Included”

Aetna covers MAT, including the following medications:

Buprenorphine/Suboxone: Widely covered. Many employer-sponsored commercial plans do not require prior authorization for buprenorphine products.
Methadone: Covered under the medical benefit when dispensed through licensed OTPs.
Naltrexone: Covered by many plans, but often through the medical benefit. It may require pre-authorization.
Naloxone: Broadly covered. Aetna has clinical policies and quantity limits.

“Out-of-Network Means No Coverage”

PPO plans cover out-of-network care, though at higher out-of-pocket costs. PPOs don’t have any restrictions on using out-of-network facilities or providers. However, they may require you to file claims yourself.

Under certain conditions, Aetna may allow you to seek out-of-network care. They may make a network gap exception or consider allowing access when in-network providers are not accessible. Aetna plans also cover out-of-network care in emergencies.

Start Your Recovery in Phoenix with Nirvana

Insurance makes quality care affordable. An insurer like Aetna goes a long way to ensure its members get the coverage they deserve. Covering behavioral health ensures people with SUDs aren’t left out. Aetna members in Phoenix can access affordable treatment.

Insurance verification isn’t always straightforward. Besides having to wait, you may come across terms that are difficult to understand. At the end of the day, you’ll have very little information about your insurance. It helps to have a partner like Nirvana Recovery. We understand the complexities of insurance. We also understand what the challenging terms mean to you. We aim to simplify insurance verification and ease your admission.

Take the first step toward recovery today with Nirvana Recovery. Let our team guide you and help you every step of the way.

Frequently Asked Questions (FAQs)

How Do I Find an In-Network Aetna Rehab In Phoenix?

Follow these steps to find an in-network Aetna rehab in Phoenix using the Aetna member portal:

Log in to your Aetna member portal. Click “Create Account” if you don’t have one.
Use the “Find a Doctor/Find a Provider” tool. Filter for “behavioral health,” “substance use,” “rehab,” or facility type. You’ll see in-network providers for your specific plan.

Does Aetna Cover Opioid and Alcohol Addiction Treatment?

Yes, it does. Aetna covers services used in the treatment of opioid and alcohol addiction. They include:

Exactly what is covered and rules like prior authorization or limits depend on your specific plan and network status.

How Much Will I Pay Out-of-Pocket for Rehab with Aetna?

It depends on the following factors:

Your plan’s details (e.g., deductible, copays, coinsurance, and out-of-pocket maximum)
Whether the facility is in-network or out-of-network
The level of care (e.g., inpatient, PHP, IOP, or standard outpatient)
The length of care
Whether MAT medications are billed to the pharmacy or the medical benefit

Can I Use Aetna for Luxury or Private Rehab Facilities?

Yes, you can. But it depends on the following:

Whether the facility is in-network or out-of-network for your specific Aetna plan
Your plan type (e.g., PPO, HMO, or EPO)
Whether Aetna approves the medical/clinical services

Many private or luxury centers contract with Aetna, so you get in-network benefits.

How Quickly Can I Start Treatment with Aetna Coverage?

It depends. It can be on the same day for emergencies, in a few days when submitting urgent pre-authorization, or up to 14 days for a standard prior authorization. It also depends on the following factors:

Your plan type
The level of care
Whether the facility is in-network or out-of-network

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