Navigating mental health and substance use treatment can be overwhelming, especially when trying to understand how insurance coverage fits into the picture. If you or a loved one is dealing with both a mental health disorder and a substance use disorder, also known as a dual diagnosis or co-occurring disorder, it's natural to wonder if your health insurance will provide access to the right kind of care.
For Californians enrolled in plans through the state’s health insurance marketplace, the question often arises: can Covered California insurance plans be used for dual diagnosis treatment? The answer is yes, but with a few important considerations. Here’s where North Penn Now steps in to assist you.
Dual diagnosis refers to a condition in which an individual experiences both a mental health disorder and a substance use disorder simultaneously. These conditions often interact and exacerbate one another, making treatment more complex.
For example, someone may experience depression and use alcohol to self-medicate, or someone with anxiety may become dependent on benzodiazepines. Because of this, treating both disorders together through an integrated care approach is crucial.
Dual diagnosis treatment typically involves a combination of psychiatric care, individual and group therapy, medication management, and evidence-based approaches to addiction recovery. The goal is not just to help someone become sober, but also to address the underlying psychological and emotional challenges that may have contributed to or worsened the addiction.
Covered California is the state’s official health insurance marketplace, created as part of the Affordable Care Act. It allows individuals and families to shop for, compare, and purchase health insurance plans. Depending on your income and eligibility, you may qualify for subsidies or even Medi-Cal, California’s Medicaid program.
All plans offered through Covered California are required to cover essential health benefits, including mental health and substance use disorder services.
This is where it becomes especially important for individuals seeking dual diagnosis treatment—because those services often fall under both mental health and substance use coverage categories. But coverage details can vary depending on the plan and provider network, so understanding the specifics of your policy is key.
Most Covered California plans include coverage for dual diagnosis treatment, although the extent of that coverage can depend on several factors. Since dual diagnosis care involves both mental health services and addiction treatment, the insurance plan must offer benefits for both types of care.
The good news is that all marketplace plans are required to offer behavioral health services as one of their essential benefits.
Using the CA Marketplace insurances for treatment typically includes outpatient mental health counseling, psychiatric services, residential substance abuse treatment, detoxification, and medication-assisted treatment. What varies is how much of those services your plan will cover, what types of treatment settings are included, and whether your chosen treatment center is within your plan’s network.
One of the biggest factors that influences how much you’ll pay for dual diagnosis treatment with a Covered California plan is whether the treatment provider is considered in-network. Most plans categorize providers into networks, and using an in-network provider generally means lower out-of-pocket costs.
For individuals seeking treatment, it’s essential to verify that the facility or provider accepts your specific Covered California plan. This often requires contacting the treatment center directly or checking with your insurance company.
Many dual diagnosis facilities in California are familiar with navigating Covered California policies and can help you understand what’s covered and what’s not.
If the treatment center you prefer is out-of-network, you may still be able to receive care, but your costs may be significantly higher. Some plans won’t cover out-of-network services at all unless it’s an emergency, while others may reimburse a portion of the cost.
Either way, it’s critical to get this clarified before starting treatment to avoid unexpected bills.
Covered California plans generally offer effective programs for co-occurring disorders. Here’s a breakdown of what is often included:
Detoxification – Medical detox is often the first step for individuals who are physically dependent on substances. This can be covered under substance use treatment benefits if medically necessary.
Residential Inpatient Treatment – Many dual diagnosis clients benefit from round-the-clock care in a residential facility. Some plans will cover this level of care if it is deemed necessary by a licensed provider.
Partial Hospitalization Programs (PHP) – This level of care provides structured treatment during the day while allowing clients to return home in the evening. It’s often covered under behavioral health outpatient benefits.
Intensive Outpatient Programs (IOP) – For those stepping down from higher levels of care, IOP offers continued support with a mix of therapy and skill-building, often multiple times per week.
Outpatient Therapy – Individual, group, and family counseling are commonly covered services that help clients continue their recovery journey.
Psychiatric and Medication Services – For individuals with mental health diagnoses, seeing a psychiatrist and having medications managed appropriately is critical, and these services are typically covered under mental health benefits.
Each of these services may have its own cost-sharing structure, such as copays, coinsurance, and deductibles. Reviewing your plan’s summary of benefits or speaking with a care coordinator can help you understand your exact responsibilities.
It’s important to be aware that many dual diagnosis services require prior authorization from your insurance provider. This means the insurer must approve the treatment before it begins to ensure it meets their criteria for medical necessity.
If your provider recommends inpatient treatment or a higher level of care, your insurance company may require documentation showing why this level of care is appropriate.
Working with a treatment center that understands how to work with insurance companies can make this process smoother. They can help gather the necessary assessments, submit paperwork, and communicate with the insurer on your behalf.
Some individuals who apply for insurance through Covered California may find that they are eligible for Medi-Cal instead, based on their income. Medi-Cal is California’s Medicaid program, and it also includes behavioral health benefits.
While the process and coverage might differ slightly from private plans, Medi-Cal does cover dual diagnosis treatment, often with fewer out-of-pocket costs.
It’s important to work with providers who accept Medi-Cal if this ends up being your form of coverage. Many community-based behavioral health centers and some private treatment facilities in California accept Medi-Cal and offer integrated dual diagnosis services.
Understanding your insurance plan is the first step to making the most of your coverage. Here are a few tips to ensure you get the help you need without unnecessary delays or costs:
Not every treatment center is equipped to handle co-occurring disorders. When evaluating programs, look for facilities that specialize in dual diagnosis and offer an integrated approach to care. This means their staff includes licensed mental health professionals and addiction specialists who work collaboratively. Programs should offer comprehensive assessments, individualized treatment planning, trauma-informed care, and aftercare support.
The best programs will also work with your insurance company to verify coverage and advocate for the care you need. Whether you’re seeking treatment in Southern California, the Bay Area, or anywhere in between, it’s important to choose a provider that understands the nuances of Covered California plans and has experience supporting clients through the recovery journey.
Covered California insurance plans can be a valuable resource for individuals in need of dual diagnosis treatment. Thanks to the essential health benefits mandated by the Affordable Care Act, these plans offer broad coverage for mental health and substance use disorder services.
While the details of each plan vary, and some services may require prior approval or be subject to network restrictions, there are many options available for Californians seeking help.
If you or someone you love is facing the challenges of co-occurring mental health and substance use issues, don’t let concerns about insurance become a barrier.
With the right information and support, accessing quality dual diagnosis treatment through a Covered California plan is not only possible—it’s a path toward long-term recovery and wellness.
