Will Insurance Cover an Addiction Caused Hospital Trip?

Will Insurance Cover an Addiction Caused Hospital Trip?

Insurance coverage can be confusing, as it can vary wildly depending upon the insurance provider and the state of residence. However, thanks to the Affordable Care Act (ACA)—which went into full effect in 2014—insurance coverage is now available for mental health and substance abuse issues. The Act requires most insurance providers to cover substance abuse and mental health issues, which means you can get medical help without draining your finances.

In every state, private insurance plans must cover a group of 10 categories that are referred to as “essential health benefits.” These essential benefits include the following list:

  • Addiction treatment and mental healthcare
  • Care for children
  • Doctor visits
  • Emergency care
  • Hospital care
  • Lab tests
  • Prescription medication
  • Physical, occupational and speech-language therapy
  • Pregnancy and maternity
  • Preventive care and treatment for chronic illness

Individual or small group insurance plans (such as those offered through a company with less than 50 full-time employees) should cover these 10 essential health benefits. Hospital and emergency room care that is related to drug abuse (such as an overdose) are also included under these plans. Medicaid plans should cover these essential health benefits as well.

However, health insurance plans offered through larger corporations that are self-insured are not required by the ACA to cover these essential health benefits, including substance abuse and mental health related issues. In other words, such employers pay medical claims out of their own pockets1. On the other hand, some large corporations cover hospital visits related to overdose and other drug-related issues. Every insurance plan is different, so ask providers what services are covered by your insurance and which are not in regard to substance abuse. People who have only recently acquired insurance may be covered for drug-related hospital or emergency room visits in concordance with the ACA, but the premiums, deductibles and co-pays for emergency care vary by state and particular providers. In short, check with your insurance provider about where you can go for what services to prepare for an emergency.

In the event of a drug overdose, emergency care, hospitalization and rehab services will probably all be necessary. The emergency services that treat overdose may include ambulance response and transportation, an emergency room visit and the services of different equipment and healthcare professionals. After the emergency has been averted, the drug user will likely need continued hospitalization depending upon her particular situation—for instance, if the overdose was intentional or accidental, then the medical care will differ. Examinations and further tests may be necessary to determine any other issues that need medical attention: the length and cost of the hospital visit will depend upon the examinations needed, the number and amount of time that different healthcare professionals are needed and the equipment and medication necessary for the visit2.

Before the ACA went into effect, all insurance providers could completely exclude (or at least heavily limit) their coverage for hospital care related to substance abuse and addiction. However, the ACA now requires all small group insurance plans and individual health insurance markets to cover addiction and mental health related services as part of the 10 essential health benefits. In regard to drug overdose, the required coverage includes emergency services, hospitalization and other services for addiction or mental health. Substance abuse disorders like addiction are seen as medical conditions that require health insurance providers to cover any harm caused by drug abuse. This idea even includes drug-related suicide attempts, such as an intentional overdose.

How to Prevent Drug-Related Hospital Visits

While most insurance plans cover hospital visits for drug-related incidents, you can take action now to prevent hospital visits and potentially life-threatening circumstances. Being covered by insurance for a drug overdose should be the least of your worries, as you could lose your life altogether to drugs without professional help. For instance, the Center for Disease Control reports that more than 27,000 people died in 2007 from unintentional drug overdoses. Furthermore, even legal drugs can lead to unintentional overdose, as someone need only abuse these substances in high enough quantities. Even people who have legally attained drugs through a doctor can still be in danger of overdose—many people obtain opioid painkillers through prescriptions, but a fatal overdose could occur if he mixes these drugs with other substances, such as alcohol, or if he takes them in too large of quantities.

In response, take the necessary steps to determine if your drug use is problematic, and then get help to avoid the dangers of substance abuse. Talk with a healthcare professional and be honest about substance abuse; meet with an addiction specialist and enter rehab if addiction is deemed a problem. If you take these steps, then you may prevent life-threatening situations.

Help Finding Professional Treatment for Substance Abuse or Addiction

If you or someone you know is struggling with substance abuse or addiction, then please call our toll-free helpline now. Our admissions coordinators are standing by 24 hours a day to help you find a professional treatment program that will work for you. Break the cycle of addiction and call us now.


1 “Health Care Reform: Health Insurance and Affordable Care Act,” WebMD, LLC, http://www.webmd.com/health-insurance/insurance-marketplace/essential-benefits, (Updated September 29, 2014).

2 “Does Health Insurance Cover Drug Overdose?” PersonalHealthInsurance.com, http://www.personalhealthinsurance.com/does-health-insurance-cover-drug-overdose/, (Cited December 13, 2015).